In-Network Provider VisionMakers www.visionmakers.com VEBA Trust Staff

1679 Woodman Drive Dayton, Ohio 45432 (937) 258-1515 VEBA Trust Vision Plan (800) 859-2733 Steve Lykins, Trust Administrator

1370 North Fairfield Road (937) 224-5230 Beavercreek, Ohio 45432 (937) 426-2212 Mark Profitt, Office Manager

650 Ridge Road (937) 224-5236 We would like to welcome you Pittsburgh, PA 15205 (412) 788-4664 to your new vision plan and (855) 814-7420 (800) 788-8701 inform you on the details; Empire Vision Katelin Mantia, Vision Department enclosed you will find all the Rochester, NY information regarding your Call VEBA for various locations For vision inquiries please call: vision benefits. Your vision Eye DR (937) 224-5235 benefit is being offered through New Jersey the IUE-CWA VEBA Trust. Call VEBA Vision for various locations (855) 224-0148 Optiview -James Clark 2200 Niles-Cortland Road Fax (937) 223-4755 Warren, Ohio 44484 Chairman, VEBA Trust (330) 544-9434

5537 Mahoning Avenue Weston Plaza Austintown, Ohio 44515 IUE-CWA VEBA Vision (330) 792-0910 313 South Jefferson Street Suite 204

Martin G. Ellis, O.D. Dayton, Ohio 45402 3018 State Route 5, Suite C Cortland, Ohio 44410 (937) 224-5235 (330) 638-4097 (855) 224-0148 Dear Vision Plan Enrollee, amount due. Reimbursements are made 3. Lenses biweekly and you are only reimbursed for a. Single Vision: No Copay In order to assist you in using your IUE- the benefit amounts listed in the Out-of- CWA VEBA Vision, we’ve compiled the Network Provider section. b. Bifocal: No Copay following details of your plan. It is our c. Tri-Focal: No Copay hope that this will provide you with a clear d. No-Line, Progressive: understanding of how the vision plan works and what you must do to receive the Benefit Eligibility Member copay $50.00 maximum benefit. e. Premium No-Line Enrollees and dependents covered under the vision plan are eligible for a Progressive: Member comprehensive eye exam and lenses once copay $125.00 What to consider when choosing every 12 months; a frame once every 24 f. Contact Lenses: No your provider months; and contact lenses will be in lieu Copay of coverage for a frame and lenses, and The In-Network Providers have all the will be provided once every 12 months. necessary forms and plan details to assist Benefits are effective as of September 1, you with your benefits. They have agreed 2011. *Make sure to let providers Out-of-Network Provider to accept your insurance coverage know if you only want fully covered Enrollees are responsible for all costs and amounts as full payment at the time of services and materials. This will expenses and the full amount due to the service. This will ensure that you only pay ensure that you only pay copayments Out-of-Network Provider. The enrollee will any amounts that exceed your allotted and the required state sales tax. be mailed a reimbursement check for the benefits at the time of service. You will following amounts, once an itemized also receive 30% off any extra retail items In-Network Provider receipt has been submitted to IUE-CWA that are purchased. These are advantages The In-Network Providers will accept your VEBA Vision. that you will only receive when using an In- benefit coverage as payment in full, and Network Provider. you will only be required to pay any 1. Comprehensive Eye Exam: applicable copayments and sales tax. Your $45.00 Under the plan, you may choose to use coverage at an In-Network Provider is as any provider. However, you will be follows: 2. Quality Optical Frame: $40.00 required to pay your full amount due at the 1. Comprehensive Eye Exam: No 3. Lenses time of your service when using an Out-of Copay -Network Provider. You will need to submit 2. Quality Optical Frame: No a. Single Vision: $35.00 an itemized receipt to IUE-CWA VEBA Copay Vision, once you have paid your total b. Bifocal: $60.00 c. Tri-Focal: $75.00

d. No Line, Progressive: $90.00

e. Contact Lenses: $110.00

Receiving a Reimbursement:

1. Contact IUE-CWA VEBA Vision to inquire on your eligibility and get prior authorization for services.

2. Submit an itemized receipt from your provider to IUE-CWA VEBA Vision.

3. Reimbursements are processed biweekly and will be mailed to your home address.

*Reimbursement schedules are subject to change.