VISION CARE What types of may I select? What /coatings are included? SUMMARY BOOKLET • Any frame from the special selection of Fashion • Plastic or glass single vision, bifocal or and Designer frames, displayed on the "Tower trifocal lenses, in any prescription range. Sky View Health Care Center is very pleased to provide Collection" in each network provider's office. Some • Glass grey #3 prescription (sunglass) lenses. you with this information about your vision care plan frames have comparable retail values up to $125.00. administered by Davis Vision, Inc., a leading national A $14.00 credit will be applied toward the purchase • Oversize lenses. administrator of routine vision care programs. Eligibility of a frame from the provider's own selection. • Post-cataract (lenticular) lenses. for vision care benefits is determined by the same rules • Fashion, sun or gradient tinted plastic lenses. that apply to your medical benefits. • Any spectacle type; many are included with • Polycarbonate lenses (for children and monocular no additional copayment. What are the plan benefits? patients). • Contact lenses, in lieu of eyeglasses; standard, soft, Annually (every 12 months) you and your covered daily-wear, disposable or planned replacement types Are there any optional frames, lens types or dependents are entitled to: are available for most prescriptions with a copayment coatings available? (see below). A $45.00 credit will be applied toward • A routine eye examination; and, other types of contact lenses including toric or gas By paying the additional low, discounted fixed fees permeable from the provider's private selection, indicated, you can receive these exciting optional item: • A complete pair of eyeglasses; or, fitting fees, and recommended follow-up care. • $20.00 for a Premier frame from the "Tower • Contact lenses, in lieu of eyeglasses. Please note: Contact lenses can be worn by most people. Collection", with retail values up to $175.00. Once the option is selected and the lenses are Who are the network providers? fitted, they may not be exchanged for eyeglasses. • $12.00 for UV (ultraviolet) protective coating. • $20.00 for Photogrey Extra (sun-sensitive) lenses. They are licensed providers who are extensively What are my costs for services? ® reviewed and credentialed to ensure that stringent • $20.00 for SuperShield® (scratch-protective) lens standards for quality service are maintained. Please • No copayment is required toward your eye call 1-800-999-5431 to access the Interactive Voice examination. coating. Response (IVR) Unit, which will supply you with the • $20.00 for blended invisible . names and addresses of the network providers near you. • No copayment is required toward a Fashion or Designer frame and/or many spectacle lenses. • $30.00 for polycarbonate lenses. How do I receive services from a provider A complete benefit (frames and lenses) from the • $35.00 for glare resistant treatment. in the network? "Tower Collection" could have a comparable retail value up $225.00! • $65.00 for Transitions® (sun-sensitive) • Call the network provider of your plastic lenses. choice and schedule an appointment. • A $25.00 or $45.00 copayment will be required toward standard, soft, daily-wear, disposable* • $55.00 for high-index (thinner and lighter) lenses. or planned replacement contact lenses, in lieu • Identify yourself as a Sky View Health • $75.00 for polaroid lenses. Care Center employee or dependent. of eyeglasses. Your provider will give you specific copayment information for the type of lenses • $50.00 for standard progressive addition multifocal you require. • Provide the office with the employee's brands. Premium progressive addition brands are Social Security number and the year of birth of any covered children needing * New (to the provider, or first-time) contact lens wearers $90.00.** services. will receive an initial supply (two multi-packs) of lenses, along with all necessary visits for proper fitting and ** Progressive addition multifocals can be worn by most recommended follow-up care. Existing contact lens people. Conventional bifocals will be supplied for anyone wearers will receive four multi-packs of lenses. It's that easy! The provider's office will verify your who is unable to adapt to progressive addition lenses; eligibility for services, and no claim forms or ID however, the copayment will not be refunded. cards are required!

SP053B 10/6/99 When will I receive my eyeglasses? Need more information? Please feel free to visit our website at www.davisvision.com or Your eyeglasses will be sent to your provider from the laboratory generally within two to five business call Davis Vision at 1-800-999-5431 to: days. Additional delivery time may be required when out-of-stock frames, glare resistant treatment, • Locate a network provider in your area. specialized prescriptions or non-"Tower Collection" frames are selected. • Verify eligibility for yourself or a family More special features: member.

• Speak with a Member Service Representative.

• Ask any questions about your vision benefits. • Free membership and access to Lens 1-2-3®, a mail order replacement contact lens service Member Service Representatives are available: providing a fast, easy convenient way to purchase replacement contact lenses at • Monday through Friday, 8:00 AM to 8:00 PM, significant savings. For more information, Eastern Time; and please call 1-800-LENS-123 (1-800-536-7123). TM • A one year unconditional breakage warranty • Saturday, 9:00 AM to 4:00 PM, Eastern Time on all eyeglasses completely supplied by Davis Vision. T.D.D. (Telephone Device for the Deaf) services are available by calling 1-800-523-2847 What about out-of-network benefits? Vision Care You must receive services from a network provider in order to obtain your vision care benefit. There is Summary Booklet no coverage when services are received from an out- of-network provider. Sponsored by, and administered on behalf May I use the benefit at different times? of the employees and dependents of: All available services must be obtained at one time from a network provider. Are there any exclusions? The following items are not covered by this vision HEALTH CARE CENTER program: croton-on-hudson, n.y. the ultimate in health care • Medical treatment of eye disease or injury. • Vision therapy. • Special lens designs or coatings, other than those previously described. • Replacement of lost eyewear. Please call Davis Vision at • Non-prescription (plano) lenses. 1-800-999-5431 • Two pairs of eyeglasses in lieu of a bifocal. with questions or visit our website:

www.davisvision.com

SP053A 10/6/99