Avēsis Advantage Plan Matrix - opticaladmin.com

1 *7IU9101C9131C914*1I9161C9171I9198C9238C 924*8I9268C9278I9329C9339I9369I93911F940 MO $10I9418H9427I9458I94717I950MO $10C951EO $0N/A95210C953EO $15N/A954EO $0N/A95613I95710I9608I961*10I962* $0I9701A97116K97210I97611C977EO $20DD978MO $0I979MO $10I980MO $10I9828J986MO $15I9877I9881J9891J9908J991MO $10J91001H91029H910310H910510I910711C911 11K91129K91138S911611H911810H9119MO $25H912010C912110I912217C9123MO $15H912410C912911I9133MO $ *11I91468K91478K914917I915216I915311C915 48H915511H916014H916217H91651H91667K9167 18H91697H917017C917216H91735I91748K91751 S918111C918911$200/$13092019K9207MO $25I92108Q92137I921411K92168S92179K9218M O $25C922111S92259S92265I92277I9228EO $0 $0J92565I92577Q925810I92591H926020$80/$2 00926114I93001V940717S97018I9900N/ADisco untD = Diabetic Eye ProgramDCPG = Internal to Av sisDisc = Up to 20% discount off retail where permissable DR = Internal to Av sisEO = Exam OnlyH = Internal to Av sisI = Industrial Safety ProgramLV = Low Vision ProgramMO = Materials OnlyN/A = No BenefitNC = Internal to Av sisNE = Internal to Av sisP = L1PG = L4U = Internal to Av sis* = may have additional benefit$/$ = Frame/CL Benefit$XXX = Retail Benefit AmountPrefix LegendCovered Lens Options PackagesT1-T7 = Transitions are covered in full along with all appropriate lens options TC1-TC7 = Transitions are added to each option for an additional $40 copayAll Options Packages

2 Include Poly up to age 19 OptionSingle VisionMultifocalPolycarbonate$40$44 Standard Scratch-Resistant Coating$17$17UV Screening $15$15 Solid or Gradient Tint$17$17 Standard Anti-Reflective Coating$45$45 Level 1 ProgressivesN/A$75 Level 2 ProgressivesN/A$110 Transitions $70$80 PGX/PBX$40$40 Polarized$75$75 Option Plans L1 and above member payment maximums if not covered by planMember Out-of-Pocket Maximum ScheduleAv sis Advantage Plan MatrixRev. 1/2018 CodeExam CopayMaterial Copay1$0$02$0$103$0$154$0$20$0EO$0 N/A5$5$106$5$157$10 $0 8$10$109$10 $15 10$10$2011$10$2512$15$013$15 $15 14$15 $20 15$15$3016$20 $0 17$20 $20 18$25$019$30 $0 20$0 $25 CopayCodeFrame BenefitC/L BenefitA$35 $75 B$35 $100 C$35 $110 D$35 $200 E$40 $95 F$45 $110 G$45 $120 H$50 $110 I$50 $130 J$50 $140 K$50 $150

3 L$50 $200 M$50 "$130/ $15 Fit"N$55 $130O$60 $130 P$65 $110 Q$65 $130 R$65 $140 S$65 $150 T$65 $200U$68 $150 V$100 $200 W$80 $175 X$65 $180 Materials BenefitIf the plan you are looking for is not listed, please visit our website to view the plan L 3 L 4 L5L6L7L 8L9L1 0 Youth Polycarbonate Adult Polycarbonate Standard Scratch-Resistant Coating Ultra-Violet Screening Solid or Gradient Tint Standard Anti-Reflective Coating Level 1 Progressives Level 2 Progressives Av sis E-Series PlansGuardian Vision PlansRev.

4 1/2018 Sample Plan Numbers050130 080200 Wholesale FrameCopay OptionsExam/MaterialsCode on ID Card0/0A10/0B10/10C10/20D10/25E10/15F15/ 0G20/0H25/0P20/20Q0/10 RCopay OptionsCopay OptionsCode on ID Card$ $ $ $ $ Only Copay OptionsRetail Frame AmountReimbursement$ $ $ $ $ $ $ $ $ $ $ $ $ $ Frame FeeContact Lens AmountReimbursement$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Lens FeeMember Out-of-Pocket Maximum ScheduleOptionSingle VisionMultifocalPolycarbonate$40$44 Standard Scratch-Resistant Coating$17$17UV Screening $15$15 Solid or Gradient Tint$17$17 Standard Anti-Reflective Coating$45$45 Level 1 ProgressivesN/A$75 Level 2 ProgressivesN/A$110 Transitions $70$80 PGX/PBX$40$40 Polarized$75$75 Covered OptionsCovered OptionsCodePolycarbonate Lenses for Adults1 Progressive Multifocals2 Anti-Reflective Coating3 Contact Lens Fitting and Evaluation4UV Coating5 High Index Lenses6 Polarized/Laminated Lenses7 Scratch-Resistant Coating8 Transitions Lenses9 Glasses and ContactsBDiabetic Eye & Low Vision PlansDOption Plan member payment maximums if not covered by planSample ID Card:130130 150200 Retail FrameCovered Lens Options PackagesT1-T7 = Transitions are covered in full along with all appropriate lens options TC1-TC7 = Transitions are added to each option for an additional $40 copayAll Options Packages include Poly up to age 19 Sample ID Card.

5 Sample Guardian Plan NumbersBACKFRONT*Standard tint, solid tint, and/or gradient tint is included in all Guardian all information on Guardian vision plans with the knowledge center on the Av sis provider portal. The plan number will only be on Q SAMPLE219865212X01/01/2011$0 COPAY9238 FAM$25 COPAY$10 COPAY$0 COPAYL1L2 L 3 L 4 L5L6L7L 8L9L1 0 Youth Polycarbonate Adult Polycarbonate Standard Scratch-Resistant Coating Ultra-Violet Screening Solid or Gradient Tint Standard Anti-Reflective Coating Level 1 Progressives Level 2 Progressives Note L1 is our standard package and includes youth polycarbonate only. L1 is not indicated on the ID card. (If applicable)Access all information on Guardian Vision plans with the knowledge center on the Av sis provider portal.

6 GUARDIAN VISION PLAN NUMBERSRev. 1/2018 PLAN NUMBERMATERIAL BENEFITCOPAY Exam/ MaterialsG120AX$1200/0G120BX$12010/0G120 HX$12020/0G120PX$12025/0G120CX$12010/10G 120FX$12010/15G120DX$12010/20G120QX$1202 0/20G120EX$12010/25G120AZ$1200/0G120BZ$1 2010/0G120HZ$12020/0G120PZ$12025/0G120CZ $12010/10G120FZ$12010/15G120DZ$12010/20G 120QZ$12020/20G120EZ$12010/25G120AY$1200 /0G120BY$12010/0G120HY$12020/0G120PY$120 25/0G120CY$12010/10G120FY$12010/15G120DY $12010/20G120QY$12020/20G120EY$12010/25G 120AV$1200/0G120BV$12010/0G120HV$12020/0 G120PV$12025/0G120CV$12010/10G120FV$1201 0/15G120DV$12010/20G120QV$12020/20G120EV $12010/25G130AX$1300/0G130BX$13010/0G130 HX$13020/0G130PX$13025/0G130CX$13010/10G 130FX$13010/15G130DX$13010/20G130QX$1302 0/20G130EX$13010/25G130AZ$1300/0 PLAN NUMBERMATERIAL BENEFITCOPAY Exam/

7 MaterialsG150HY$15020/0G150PY$15025/0G15 0CY$15010/10G150FY$15010/15G150DY$15010/ 20G150QY$15020/20G150EY$15010/25G150AV$1 500/0G150BV$15010/0G150HV$15020/0G150PV$ 15025/0G150CV$15010/10G150FV$15010/15G15 0DV$15010/20G150QV$15020/20G150EV$15010/ 25G200AX$2000/0G200BX$20010/0G200HX$2002 0/0G200PX$20025/0G200CX$20010/10G200FX$2 0010/15G200DX$20010/20G200QX$20020/20G20 0EX$20010/25G200AZ$2000/0G200BZ$20010/0G 200HZ$20020/0G200PZ$20025/0G200CZ$20010/ 10G200FZ$20010/15G200DZ$20010/20G200QZ$2 0020/20G200EZ$20010/25G200AY$2000/0G200B Y$20010/0G200HY$20020/0G200PY$20025/0G20 0CY$20010/10G200FY$20010/15G200DY$20010/ 20G200QY$20020/20G200EY$20010/25G200AV$2 000/0G200BV$20010/0G200HV$20020/0 PLAN NUMBERMATERIAL BENEFITCOPAY Exam/ MaterialsG130BZ$13010/0G130HZ$13020/0G13 0PZ$13025/0G130CZ$13010/10G130FZ$13010/1 5G130DZ$13010/20G130QZ$13020/20G130EZ$13 010/25G130AY$1300/0G130BY$13010/0G130HY$ 13020/0G130PY$13025/0G130CY$13010/10G130 FY$13010/15G130DY$13010/20G130QY$13020/2 0G130EY$13010/25G130AV$1300/0G130BV$1301 0/0G130HV$13020/0G130PV$13025/0G130CV$13 010/10G130FV$13010/15G130DV$13010/20G130 QV$13020/20G130EV$13010/25G150AX$1500/0G 150BX$15010/0G150HX$15020/0G150PX$15025/ 0G150CX$15010/10G150FX$15010/15G150DX$15 010/20G150QX$15020/20G150EX$15010/25G150 AZ$1500/0G150BZ$15010/0G150HZ$15020/0G15 0PZ$15025/0G150CZ$15010/10G150FZ$15010/1 5G150DZ$15010/20G150QZ$15020/20G150EZ$15 010/25G150AY$1500/0G150BY$15010/0 PLAN NUMBERMATERIAL BENEFITCOPAY Exam/ M a

8 T e r i a l s G200PV$20025/0G200CV$20010/10G200FV$2001 0/15G200DV$20010/20G200QV$20020/20G200EV $20010/25GM135JY$1350GM135JZ$1350GM135JX $1350GM135LY$13510GM135LZ$13510GM135LX$1 3510GM135MY$13520GM135MZ$13520GM135MX$13 520GM135NY$13525GM135NZ$13525GM135NX$135 25GM150JY$1500GM150JZ$1500GM150JX$1500GM 150LY$15010GM150LZ$15010GM150LX$15010GM1 50MY$15020GM150MZ$15020GM150MX$15020GM15 0NY$15025GM150NZ$15025GM150NX$15025GM200 JY$2000GM200JZ$2000GM200JX$2000GM200LY$2 0010GM200LZ$20010GM200LX$20010GM200MY$20 020GM200MZ$20020GM200MX$20020GM200NY$200 25GM200NZ$20025GM200NX$20025GE-JYN/A0GE- LYN/A10GE-MYN/A20GE-NYN/A25 CONTACT LENS ALLOWANCE REIMBURSEMENT CHANGES EFFECTIVE 1/1/2017 Advantage Plans and E-Series Wholesale Plans: The member s contact lens allowance may be applied toward the fitting and/or the lenses themselves.

9 Av sis reimburses 85 percent of the benefit allowance. Members are responsible for 90 percent of the remaining balance in excess of their benefit allowance. E-Series Retail Plans: The member s contact lens allowance is applied to the contact lenses, only. Av sis reimburses 85 percent of the benefit allowance. Members are responsible for 90 percent of the remaining balance in excess of their benefit allowance. The Contact Lens Exam, Fitting, And Follow-Up (CLEFFU) is a separate service, and the extent of coverage is determined by the member s specific plan. CLEFFU is only available with the new E-Series Retail OPTIONS ON E-SERIES RETAIL PLANS ONLYTo determine the member s CLEFFU benefit, simply look at the plan number: 1 = Member s out-of-pocket maximum is $50 standard and $75 custom.

10 Members may use their eyeglass benefit with their CLEFFU. 2 = Member s copayment is $25 standard and $50 custom. Av sis reimburses $25 to the provider. CLEFFU is in lieu of eyeglass benefit. 3 = Member has no copayment. Av sis reimburses the provider $50 standard and $75 custom. CLEFFU is in lieu of eyeglass benefit.*Product codes: standard, 92310; custom, S0592.