PPO

Vision Care

Vision Care benefits are provided to the UN programme participants by Davis Vision under contract to Empire Blue Cross.

The Vision Care benefits include an eye exam and eyewear, consisting of a select group of frames, and soft contact lenses once every 12 months. During this benefit period, you are not required to purchase the eyewear at the time of the examination, nor are you required to purchase the covered eyewear from the same provider who rendered the eye examination.

To find a participating Davis Vision Network provider in your area, simply call 1-888-EYEBLUE (1-888-393-2583) between 9 a.m. and 5 p.m. weekdays, or visit their web site at www.davisvision.com.

Service	Amount you pay
Eye Exam	$15.00
Frames (Limited Selection)	$10.00
Premier Frames	$40.00
Soft Contact Lenses - per pair (standard daily wear)	$10.00
Disposable Contact Lens	$10.00
Single Vision Lenses	0
Bifocal Lenses	0
Trifocal Lenses	0
Premium Progressive Addition Lenses	$90.00
Blended Segment Lenses	$20.00
Photochromatic or Supershield Single Vision Lenses	$20.00
Photochromatic or Supershield Multifocal Vision Lenses	$20.00
Ultraviolet Coating	$12.00
Reflection-Free Coating	$35.00
Polaroid Lenses	$75.00
Polycarbonate Lenses	$30.00
High Index Lenses	$55.00
Transition Lenses	$65.00

In addition, Vision Care benefits include a $35 allowance for non-plan frames and a $75 allowance for non-plan contact lenses. Note: "non-plan" means purchased at Davis Vision but not from the plan-approved lenses or frames. Davis Vision will advise you on the plan-approved lenses and frames at the time of your visit.

Out-of-network Vision Care allowances include $30 for an eye exam with a non-plan provider, and an out-of-network allowance of $30 for frames, $25 for single vision lenses, $35 for Bifocal lenses and $45 for Trifocal lenses, or there is an out-of-network contact lens allowance of $75. Claims for out-of-network allowance must be submitted to Davis Vision for reimbursement, not to Empire Blue Cross. The Davis Vision claim form can be printed at their website which is http://www.davisvision.com.

Laser vision correction: Participants are reminded that discounts are available for laser vision correction from Davis Vision. To receive information regarding the laser vision correction savings, go to http://www.davisvision.com on the Internet and click on "laser vision correction" and proceed to "laser vision correction program", which will require your Blue Cross member ID number (the number on your Blue Cross card) or login name and password. If you have not yet established a login name and password, go to www.empireblue.com and register by entering "member" in the "I am a:" drop-down menu and clicking on the "register" button (see also paragraph below on Empire's Internet site). For more information on the laser vision correction programme, contact Davis Vision at 1-877-92DAVIS.