USVI Public Records

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The Government of the US Virgin Islands Eye Care Highlight Sheet Standard Insurance Company Benefit and Cost Summary Highlight Sheet Plan 1: Balanced Care Vision II Plan H Summary Effective Date: 10/1/2013 EyeMed Access Network Out of Network Deductibles $0 Exam No deductible $0 Eye Glass Lenses Annual Eye Exam Covered in full Up to $40 Lenses (per pair) Single Vision Covered in full Up to $40 Bifocal Covered in full Up to $60 Trifocal Covered in full Up to $80 Lenticular Covered in full Up to $80 Progressive See lens options NA Contacts Fit & Follow Up Exams Standard Standard: Participant cost up to $55 No benefit Premium (Allowance) Premium: 10% off of retail No benefit Elective Up to $150 Up to $150 Medically Necessary Covered in full Up to $210 Frames $150 Up to $45 Frequencies (months) Exam/Lens/Frame 12/12/24 12/12/24 Based on date of service Based on date of service Lens Options (participant cost) EyeMed Access Network Out of Network Progressive Lenses No benefit Standard Standard: $65 + lens deductible Premium Premium: lens cost - 20% discount - $120 allowance + Standard Progressive cost Std. Polycarbonate $40 No benefit Tint (solid and gradient) $15 No benefit Scratch Resistant Coating $15 No benefit Anti-Reflective Coating $45 No benefit Ultraviolet Coating $15 No benefit Lasik or PRK Average discount of 15% off retail price or 5% off promotional price at US Laser Network participating providers. No benefit Government of the USVI - ACTIVE Employee Only (EE) $4.14 EE + Family $11.00 Government of the USVI – RETIREES Employee Only (EE) $4.14 EE + Family $11.00 The Government of the US Virgin Islands Eye Care Highlight Sheet Standard Insurance Company Benefit and Cost Summary Highlight Sheet Additional Balanced Care Vision II H Features EyeMed In-Network Discounts 15% discount off the remaining balance in excess of the conventional contact lens allowance. 20% discount off the remaining balance in excess of the frame allowance. 20% discount on items not covered by the plan at network providers, which may not be combined with any other discounts or promotional offers. This discount does not apply to EyeMed Provider's professional services, or contact lenses. EyeMed In-Network Secondary Purchase Plan Participants receive a 40% discount on a complete pair of glasses once the funded benefit has been exhausted. Participants receive a 15% discount off the retail price on conventional contact lenses once the funded benefit has been exhausted. Discount applies to materials only. Contact Lens Replacement by Mail Program After exhausting the contact lens benefit, replacement lenses may be obtained at significant discounts on-line. Visit EyeMedvisioncare.com for details. Eye Care Plan Participant Service Balanced Care Vision II eye care from The Standard features the money-saving eye care network of EyeMed Vision Care. Customer service is available to plan participants through EyeMed's well-trained and helpful service representatives. Call or go online to locate the nearest EyeMed Access network provider, view plan benefit information and more. EyeMed Customer Care Center: 1-866-289-0614  Service representative hours: 8 a.m. to 11 p.m. ET Monday through Saturday, 11 a.m. to 8 p.m. ET Sunday  Interactive Voice Response available 24/7 Section 125 This plan is provided as part of the Policyholder's Section 125 Plan. Each employee has the option under the Section 125 Plan of participating or not participating in this plan. If an employee does not elect to participate when initially eligible, he/she may elect to participate at the Policyholder's next Annual Election Period. This form is a benefit highlight, not a certificate of insurance.