Taking care of your vision benefits.
The Pennsylvania Builders
Association Benefits Trust is proud to offer our members the following vision
insurance plan.
Benefit Summary
Services
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In-Network
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Out-of-Network Reimbursement
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Eye Examinations
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Member, spouse, children are 19 and over
(every 24 months)
Children under age 19
(every 12 months)
Including dilation as professionally indicated.
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$0 copayment
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up to $32
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Frames (every 24 months)
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Fashion Selection from the exclusive
"Tower Collection" in most network provider offices. A $60.00
credit toward any other frame at a participating provider office. When
receiving services from a provider who does not have the collection (such
as a participating retail center) the credit will be applied to your purchase.
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$0 copayment
for Fashion selection
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up to $30
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Spectacle Lenses (per pair)
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Member, spouse, children are 19 and over
(every 24 months)
Children under age 19
(every 12 months)
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$0 copayment for standard lenses
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Single Vision
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up to $25
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Bifocal
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up to $36
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Trifocal
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up to $46
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Lenticular
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up to $72
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Contact Lenses (per dispense)
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Member, spouse, children are 19 and over
(every 24 months)
Children under age 19
(every 12 months)
Standard, Soft daily-wear, disposable* or planned replacement contact lenses
may be selected in lieu of eyeglasses. A $85.00 credit will be applied
toward contact lenses from the provider's own supply (such as gas permeable
or toric). When receiving services from a participating retail center,
the credit will be applied toward the purchase of contact lenses and fitting/follow
up fees. Where required by state law, the full credit may be applied toward
contact lenses only.
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$0 copayment for plan supplied contact lenses
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up to $85
for cosmetic
contact lenses
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Medically necessary contact lenses (prior
approval required)
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covered in full
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up to $225
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Please Note: Contact lenses can be worn by most
people. Once the contact lens option is selected and the lenses are fitted,
they may not be exchanged for eyeglasses.
- Disposable contact lens wearers will receive
four multi-packs of lenses. Planned replacement contact lens wearers will
receive two multi-packs of lenses.
Monthly Rates
These rates are effective July 1, 2008 through June 30, 2009 for new groups and include the PBA Benefits Trust administrative fee. Please note, groups that enrolled between July 1, 2007 and May 30, 2008 will keep their current rates.
All Pennsylvania Counties
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Group Type
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Monthly Rates
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Single
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Non-Sole - $3.13
Sole - $3.43
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2 Person or Family
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Non-Sole - $8.54
Sole - $9.64
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Frequently Asked Questions
How do I receive
services from a provider in the network?
- Call the network provider of
your choice and schedule an appointment.
- Identify yourself as Davis Vision
plan participant.
- Provide the office with the
employee's ID number and the date of birth of any covered children needing
services. It's that easy! The provider's office will verify your eligibility
for services, and no claim forms or ID cards are required!
Who are the network providers?
They are licensed providers who are extensively reviewed and credentialed to
ensure that stringent standards for quality service are maintained. Please
call 1-800-999-5431 to access the Interactive Voice Response (IVR) Unit,
which will supply you with the names and addresses of the network providers
nearest you, or you may access our website at www.davisvision.com and utilize our "Find
a Doctor" feature.
What about out-of-network
provider benefits?
You may receive services from an out-of-network provider, although you
will receive the greatest value and maximize your benefit dollars if you
select a provider who participates in the network. If you choose an out-of-network
provider, you must pay the provider directly for all charges and then submit
a claim for reimbursement to:
Vision Care Processing Unit
P.O. Box 1525
Latham, NY 12110
To request claim forms, please visit the Davis Vision website at www.davisvision.com or
call 1-800-999-5431.
What lenses/coatings
are included?
- Plastic or glass single vision,
bifocal or trifocal lenses, in any prescription range.
- Oversize lenses.
- Post-cataract lenses.
- Fashion, sun or gradient tinted
prescription plastic lenses.
- Polycarbonate lenses for dependent
children, monocular patients and patients with prescriptions +/- 6.00 diopters
or greater.
Are there any optional frames, lens types or coatings
available?
Yes, you can pay the low, discounted fixed fees indicated and receive these
exciting optional items:
- $20.00 for a Designer frame
from the "Tower Collection".
- $40.00 for a Premier frame from
the "Tower Collection".
- $15.00 for glass grey #3 prescription
lenses.
- $35.00 for polycarbonate lenses.
- $20.00 for scratch-resistant
coating.
- $20.00 for Photogrey ExtraÆ
(photosensitive) glass lenses.
- $15.00 for ultraviolet (UV)
coating.
- $40.00 for standard ARC (anti-reflective
coating). Premium ARC is $55.00.
- $75.00 for polarized lenses.
- $30.00 for intermediate vision
lenses.
- $20.00 for blended invisible
bifocals.
- $70.00 for plastic photosensitive
lenses.
- $60.00 for high-index (thinner
and lighter) lenses.
- $65.00 for standard progressive
addition multifocal lenses. Premium progressive additional lenses are $105.00.**
** Progressive addition multifocals can be
worn by most people. Conventional bifocals will be supplied at no additional
charge for anyone who is unable to adapt to progressive addition lenses;
however, the copayment will not be refunded.
Laser Vision
Correction Services:
Davis Vision is pleased to provide you and your eligible dependents with
the opportunity to receive Laser Vision Correction Services at significant
discounts through a network of experienced, credentialed surgeons (please
note that some providers have flat fees equivalent to these discounts).
For more information, please visit our website at www.davisvision.com or
call 1-800-999-5431.
Mail Order Contact
Lenses:
Free membership and access to a mail order replacement contact lens service,
Lens 123, providing a fast and convenient way to purchase replacement contact
lenses at significant savings. For more information, please call 1-800-LENS-123
(1-800-536-7123) or visit the Lens 123 web site at www.Lens123.com.
Your rights as
a patient:
Davis Vision recognizes that all patients have specific rights, including,
but not limited to:
- The right to complete information
about their healthcare options and consequences.
- The right to participate in
all treatment decisions.
- The right to dignity, privacy,
confidentiality and non-discrimination.
- The right to complain or appeal
any decision. Patients also have the responsibility:
- To provide complete and accurate
information.
- To follow care instructions.
For a complete copy of Your Rights and Responsibilities
As a Patient, please visit our website at: www.davisvision.com or
call 1-800-999-5431.
For additional information:
Please call Davis Vision at 1-800-999-5431 with questions or visit our website: www.davisvision.com.
Member Service Representatives are available: Monday through Friday, 8:00 AM
to 8:00 PM, Eastern Time, and; Saturday, 9:00 AM to 4:00 PM Eastern Time. Participants
who use a TTY (Teletypewriter) because of a hearing or speech disability may
access TTY services by calling 1-800-523-2847.
Note: By clicking on the links above you will
be leaving our site and a new browser page will open. This page will also
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