Microsoft Word - IN-V0109-0001-2106299-Vision_130_Std_Summary-F0399697

® DeltaVision® DeltaVision Summary of Vision Plan Benefits For Group #V0109‐0001 Huntington County Community School Corporation Employee Benefit Trust This Summary of Vision Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your DeltaVision plan. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the Provider’s network participation.* Control Plan – Delta Dental of Indiana Benefit Year – January 1 through December 31 Delta Dental will provide vision care Benefits according to the Schedule listed below. This Schedule lists the vision care Benefits to which Members are entitled, subject to any applicable Copayments and other conditions, limitations and/or exclusions stated herein. Administrative Services for the adjudication of claims and the payment of Benefits under this Policy will be provided by Vision Service Plan Insurance Company (“VSP”), using a VSP network of Providers. VSP is sometimes referred to as the claims administrator for this Policy. If Benefits are available for Out‐of‐Network Provider services, as indicated by the reimbursement provisions below, Benefits may be received from any licensed eye care provider whether an In‐Network or Out‐of‐Network Provider. This Summary forms a part of the Contract to which it is attached. In‐Network Providers are those Providers who have agreed to participate in the VSP Choice Network. When Benefits are received from In‐Network Providers, Benefits appearing in the In‐Network Benefit column below are applicable subject to any applicable Copayments and other conditions, limitations and/or exclusions as stated below. When Benefits are received from Out‐of‐Network Providers, Member is reimbursed for such Benefits according to the schedule in the Out‐of‐Network Provider Benefit column below, less any applicable Copayment. The Member pays the Provider the full fee at the time of service and submits an itemized bill to Delta Dental’s claims administrator for reimbursement. Discounts do not apply for Benefits obtained from Out‐of‐Network Providers. Covered Services – COVERED SERVICE OR IN‐NETWORK OUT‐OF‐NETWORK PROVIDER FREQUENCY MATERIAL PROVIDER BENEFIT BENEFIT Eye Examination Covered in full* Up to $45* Available once each 12 months** Retinal Screening Covered for a maximum Included in exam Available once every 12 months** fee of $39 Complete initial vision analysis: includes appropriate examination of visual functions and prescription of corrective eyewear where indicated. *Less any applicable Copayment. **Beginning with the first date of service. VINPPOSUMM092022 1 KR#84491430