Davis Vision

BlueExtrasSM Vision Discount Program

Discount vision program Mail order contact lenses ® Blue Cross and Blue Shield of Texas (BCBSTX), a division of The Lens 1 2 3 Mail Order Contact Lens Replacement Health Care Service Corporation, is pleased to offer members a Program is a fast and convenient way to purchase replacement discount vision program through Davis Vision, Inc., a leading contact lenses at significant savings. For more information, national provider of routine vision care programs. Save on call 800-LENS-123 (800-536-7123) or visit the Lens 1 2 3 eyeglasses and receive discounts on contact lenses, eye exams website at lens123.com. and accessories with Davis Vision. Are there any exclusions? How do I locate a The following items are not covered by this vision Davis Vision provider? discount program: The Davis Vision network consists of major national and o Medical treatment of eye disease or injury regional retail locations, such as EyeMasters and Visionworks, o Vision therapy as well as independent ophthalmologists and optometrists. o Special lens designs or coatings, For a list of Davis Vision providers near you just log in to other than those listed in the Blue Access for MembersSM (BAM) at bcbstx.com. Click on fee schedule on the back of the My Coverage tab at the top, and then the BlueExtras this page Discount Program link. o Services performed by a How to maximize your benefits provider who is not in the Davis Vision network o Your health plan may offer some level of vision benefits. If your plan offers vision benefits, you should continue to o Replacement of lost eyewear follow network guidelines for your routine eye exams. o Services not performed o If your optometrist or ophthalmologist is a Davis Vision by licensed personnel provider or if you use a Davis Vision provider for products For more information, and services, you can receive discounts on frames, lenses call Davis Vision and contacts by presenting your BCBSTX ID card. at 800-501-1459 Discounts are only available at Davis Vision providers. or visit davisvision.com, click Members and Laser vision correction enter Control Code Davis Vision is pleased to provide you and your eligible 2295 in the Open dependents with the opportunity to receive discounts on Enrollment section. laser vision correction services through the TruVision network. To schedule an appointment call TruVision directly at 877-882-2020 or contact Davis Vision at 800-501-1459 for more information. bcbstx.com Davis Vision

Eye exam and vision hardware discount fee schedule1 Eye Examinations2 If your plan offers vision benefits, see your BCBSTX or Davis Vision network provider for your initial eye exam. You can receive the following discounts on any additional exams or hardware when using a Davis Vision provider.

You Pay: Examinations Comprehensive examination 15% off or $5 off retail cost Contact lens examination 15% off or $10 off retail cost Frames3 Priced up to $70 retail $40 $40 plus 10% Priced over $70 retail off the amount over $70 Spectacle Lenses (Uncoated plastic)3 Single vision $35 Bifocal $55 Trifocal $65 Lenticular $110 BlueExtras offers Contact Lenses members and covered Conventional2 20% off dependents access to Disposable/Planned replacement2 10% off Spectacle Lens Options (Add to lens prices)3 discounts on a variety of Standard progressive4 $60 or $75 health care and wellness 4 Premium progressive $110 or $125 products and services. Glass lenses $18 Polycarbonate lenses $30 Blended invisible bifocals $20 Intermediate vision lenses $30 Photogrey Extra® lenses $35 Scratch-resistant coating $15 Anti-reflective coating $45 Ultraviolet coating $15 Solid tint $10 Gradient tint $12 Hi-index lenses $55 Plastic photosensitive lenses $65 Polarized lenses $75

1 At Wal-Mart, members will receive comparable values on examination, spectacle lens and contact lens purchases. Members buying frames at Wal-Mart will receive a flat ten percent discount off of Wal-Mart’s price, rather than the discounts above 2 Discount will be applied to the provider’s usual and customary price for services 3 Special lens designs, materials, powers and frames may require additional cost 4 Pricing at some retail locations may vary The relationship between these vendors and Blue Cross and Blue Shield of Texas (BCBSTX) is that of independent contractors. BlueExtras is a discount program available to BCBSTX members. Some of the services offered through BlueExtras may be covered under your health plan. Please refer to your benefit booklet or call the customer service number on the back of your ID card for specific benefit information under your health plan. Use of BlueExtras does not affect your premium, nor do costs of BlueExtras’ services or products count toward any maximums and/or plan deductibles. Discounts are only available through participating vendors. BCBSTX does not guarantee or make any claims or recommendations regarding the services or products offered under BlueExtras. You may want to consult with your physician prior to use of these services and products. Services and products are subject to availability by location. BCBSTX reserves the right to discontinue or change this discount program at any time without notice. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 48902.0611