Archdiocese of St. Louis

2020 DeltaVision Benefit Plan Overview

When electing medical coverage, you are automatically enrolled in dental, and effective 7/1/2020, you will be automatically enrolled in DeltaVision, our Vision Plan through Delta Dental.

Large National Vision Provider Network

As a DeltaVision member you have access to the Superior VisionTM National network, one of the largest and most diverse provider networks in the nation. The Superior VisionTM National network has more than 100,000 access points with independent providers and 50 major retail optical chains including Costco, Walmart, Sam’s Club, Target, LensCrafters, and more.

The Benefits of DeltaVision

• More Eye Care Providers: 50 major retail optical chains, plus independent providers and an online provider for ordering contacts—all in-network.

• More Options: You can get eye exams at one place and buy eyewear at another for greater selection.

• More Freedom: You are free to choose from any brand, lens type and price point on eyeglass frames or contact lenses.

• In-network Vision Care Providers Save you Money: By participating in the Superior VisionTM National network, vision care providers agree to specified fee schedules which reduces out of pocket costs for you.

• Online Retailers: ContactsDirect offers DeltaVision members the same seamless in-network experience when shopping for contact lenses online as they do in store.

• Additional savings with the DeltaVision Value Discounts - Our discount program delivers even greater value and more savings. In addition to receiving covered benefits, members also get special deals on popular extras.

• Laser Vision Correction (LASIK) - Through Qualsight®, DeltaVision members have nationwide access to refractive surgeons and leading LASIK providers who offer members discounts up to 50% off.

DeltaVision Frequently Asked Questions

What is DeltaVision and who is Superior VisionTM? DeltaVision is the name of Delta Dental of Missouri’s vision benefits offerings. DeltaVision plans utilize the Superior Vision National network — one of the largest and most diverse provider networks in the nation. Superior Vision handles customer service and claims processing for DeltaVision members. There may be times when Superior Vision is mentioned in place of DeltaVision, such as when members receive their ID card in the mail or when members call customer service. Delta Dental of Missouri and Superior Vision work together to provide the best experience for our DeltaVision members.

How can I reach customer service? Customer service representatives are available Monday through Friday from 7 a.m. until 8 p.m. Central Time and on Saturday from 10 a.m. until 3:30 p.m. Central Time You may reach them by phone at 1-844-549-2603, or by email at [email protected].

Will I need my ID card for my appointments? Although an ID card is not required, members should present their ID card at the time of service to help expedite the process.

What if I lose my DeltaVision® ID card? Note that the ID Card is not required for services to be rendered. In the event of a lost or misplaced member ID card, please contact our customer service center at 1-844-549-2603 for a replacement.

What is my member identification number? Your unique member ID number can be found on your DeltaVision ID card.

Will I be required to pay a co-pay when I visit a provider? Co-pays are plan and service specific. To determine your co-pay amount, log in to your DeltaVision account. You will need to create an account using your date of birth and member ID before being able to log in to the portal at DeltaDentalMO.com/Vision.

Do I need a claim form if I see a network provider? Claim forms are not required for services received from in-network providers. Participating providers will file all in-network claims.

How do I get reimbursed for an out-of-network visit? Out-of-network providers require members to pay for their services. You will need to submit a Member Reimbursement Claim Form with a copy of the original receipt to:

Superior Vision Attn: Claims Processing P.O. Box 967 Rancho Cordova, CA 95741 Fax: (916) 852-2277

Can I choose contact lenses instead of eye glasses? Yes, subject to plan frequency and co-pay, you can use your benefits to purchase contact lenses in lieu of eye glasses.

I am interested in LASIK. What coverage do I have? Through QualSight®, members can receive up to 50% off of the national average price of traditional LASIK with over 1,000 locations to choose from nationwide. Additionally, there are:

• No authorizations required by DeltaVision. • No copayments needed. • DeltaVision members are informed of the exact contracted prices during their initial phone consultation. • To get started, call 1-877-201-3602 or visit lasik.sv.qualsight.com for more information on LASIK benefits.

How can I find an in-network provider? Provider information is updated and made available to members via:

• Website. At DeltaDentalMO.com/Vision, members can use our online provider search engine to locate a provider. Members can find providers, based on distance from a city, state and ZIP with a search radius between five and 50 miles. The results can include a printable provider directory and driving directions with a map for easy reference. • Email. Members may email provider location requests to [email protected]. • Customer Service. Members can call our toll-free telephone number, 844-549-2603, Monday through Friday from 7 a.m. until 8 p.m. Central Time and on Saturday from 10 a.m. until 3:30 p.m. Central Time.

VISION BENEFITS SUMMARY

Archdiocese of St. Louis Effective Date: July 1, 2020 COVERAGE IN-NETWORK OUT-OF-NETWORK 1 EXAMS $10 copay $10 copay Comprehensive Eye Examination (with dilation) Covered in full after copay Reimbursed up to $40 $40 allowance Contact Lens Fit & Follow-up Not covered (copay does not apply) MATERIALS $25 copay $25 copay Eyeglasses 2 (in lieu of contact lenses) Standard Plastic CR-39 Lenses Reimbursed up to: ▪ Single ▪ Single: $20 ▪ Bi-focal Covered in full after copay ▪ Bi-focal: $40 ▪ Tri-focal ▪ Tri-focal: $60 ▪ Lenticular ▪ Lenticular: $100 Standard Frames $150 retail allowance Reimbursed up to $60

Contact Lenses 3 (in lieu of eyeglass lenses and frames) Elective Contact Lenses $150 retail allowance Reimbursed up to $90 Medically Necessary Contact Lenses 4 $250 retail allowance Reimbursed up to $250 LENS UPGRADES Available when you use your eyeglass lens benefit Polycarbonate Lenses Covered in full Not covered (members age 19 and under) (copay does not apply) Standard Progressive Lenses Additional $50 copay Not covered Photochromic Lenses Additional $60 copay Not covered 1. For out-of-network services, you will be reimbursed up to the amount shown, less your copay. 2. A single materials copay applies to standard lenses and frames when purchased together. 3. This benefit is paid only once during your benefit period and must be fully utilized at the time of purchase. 4. Only available for conditions of aphakia, keratoconus, or severe anisometropia.

BENEFIT FREQUENCY DELTAVISION VALUE DISCOUNTS Eye Exam Every 12 months Covered members can take advantage of discounted services and materials at participating discount provider locations. Eyeglass Lenses Every 12 months Polycarbonate Lenses 1 (members over age 19): $40 Eyeglass Frames Every 24 months Frames : 20% off amount over allowance Contact Lenses Every 12 months Laser Vision Correction : Member discounts up to 50% 1 Only applies to single vision lenses. The discount features are not insurance and may be subject to change without notice. Not all providers participate in DeltaVision Value Discounts. Call your provider or visit our website to confirm if they offer discounts. REFER TO YOUR CERTIFICATE OF COVERAGE FOR FULL COVERAGE DETAILS, LIMITATIONS AND EXCLUSIONS. For a copy of your Certificate of Coverage, consult your plan administrator. DeltaVision® is underwritten by Advantica Insurance Company and administered by Delta Dental of Missouri and Superior Vision Services, Inc. Advantica Insurance Company’s trade name and mark are owned by Delta Dental of Missouri. Superior Vision™’s trade name and mark are owned by Versant Health. Advantica Insurance Company and Superior Vision are not sponsored or endorsed by the Delta Dental Plans Association. Delta Dental and DeltaVision are registered trademarks of the Delta Dental Plans Association. IMPORTANT TO REMEMBER!

Here are some tips to help you get the most out of your DeltaVision benefits:

• Copays apply to all benefits except where noted. • When the benefit includes an allowance, you are responsible for charges over that allowance in addition to the applicable copay. • When you visit an in-network provider, you are responsible for your exam copay at the time of your visit and your materials copay at the time of your purchase. • If you use an out-of-network provider, you must pay the full cost of the services provided at the time they are received. Submit your claim to DeltaVision within 12 months of the date of service for reimbursement. You will be reimbursed up to the amount shown, less your copay. • Exam and material frequencies will restart at the beginning of each benefit year. Your benefit year runs from your group’s effective date. CONVENIENT ACCESS TO VISION CARE

Your plan utilizes the Superior Vision™ National network. To find participating vision care providers, visit us online at www.deltadentalmo.com/vision . • America's Best Contacts • Costco Optical • Meijer Optical • Sterling Optical and Eyeglasses • Eyeglass World • MyEyeDr. • • Boscov's Optical • • Nationwide Vision • • Clarkson Eyecare • For Eyes • Pearle Vision • Walmart Vision Center • Cohen's Fashion Optical • JCPenney Optical • Sam's Club Optical • Contactsdirect • LensCrafters • Shopko Eyecare Center

DELTAVISION MEMBER SUPPORT

If you have questions or need support, we’re here to help. Visit us online at www.deltadentalmo.com/vision .

58267_0.0000 DVMO-190724-1186 DeltaVision Value Discounts Additional Valuable Savings for Vision Plan Members With DeltaVision coverage and the Superior VisionTM National network, members get comprehensive, quality benefits at a ordable rates. And that’s just the beginning. Our discount program delivers even greater value and more savings. In addition to receiving covered benefits, members also get special deals on popular extras. Covered members can take advantage of the following discounted services and materials at participating discount provider locations. To see if your provider participates in the DeltaVision Value Discounts plan, visit our website at DeltaDentalMO.com/Vision and click on “Find a Vision Provider”. Search for your provider and look for “Discount Features” under the “Services O ered” section. Discounts on covered materials Maximum member out-of-pocket The following options have out-of-pocket Frames: 20% o amount over allowance maximums1 on standard (not premium, brand, or progressive) lenses. Lens options: 20% o retail Single Vision Bifocal & Trifocal

Progressives: 20% o amount over retail lined trifocal lens, including lens options Scratch coat: $13 $13

Ultraviolet coat: $15 $15 Discounts on non-covered exam and materials Tints, solid or gradients: $25 $25

Exams, frames, and prescription lenses: 30% o retail Anti-reflective coat: $50 $50

Lens options, contacts, other prescription Polycarbonate: $40 20% o retail 20% o retail materials: High index 1.6: $55 20% o retail Disposable contact lenses: 10% o retail

$39 maximum Photochromic: $80 20% o retail Retinal imaging: member out- of-pocket Laser vision correction (LASIK) Through Qualsight®, DeltaVision members have nationwide access to refractive surgeons and leading LASIK providers who o er members discounts up to 50% o .

1 Discounts and maximums may vary by lens type-please check with your provider. Not all providers participate in DeltaVision Value Discounts. Call your provider prior to scheduling an appointment to confirm if they o er discounts. The discount features are not insurance. Discounts are subject to change without notice. Discounts do not apply if prohibited by the manufacturer. The DeltaVision Value Discounts Program is administered by Superior Vision Services, Inc. Delta Dental and DeltaVision are registered trademarks of Delta Dental Plans Association.

DeltaDentalMO.com @DeltaDentalMO Facebook.com/DeltaDentalMO DVMO-191119-1368 How to Search for a Vision Care Provider Finding a vision care provider is easy using our online directory at DeltaDentalMO.com/Vision

DeltaVision gives you the option to choose from a wide variety of national retail locations or independent providers with the Superior VisionTM National network. With 50 major retail optical chains, plus independent providers and online contacts, employees can easily find a provider that is right for them.

Find a Provider At DeltaDentalMO.com/Vision, point to Find a Provider in menu bar at the top of the page and click on Find a Vision Provider.

Enter the following information: Location Use this section to enter your address or zipcode. Search Radius You are given the option to search 1, 2, 5, 10, 20 or 40 miles from your location.

Click Search Your results will be listed on this page. Within the results is the address, services oered and the doctors participating at this location. Providers who participate in the discount program will show "Discount Features" listed under "Services Oered".

DeltaDentalMO.com @DeltaDentalMO Facebook.com/DeltaDentalMO DVMO-200220-1383