Brandywine Benefits -- Life and AD&D Insurance

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Vision Care
What Is Covered

Whether or not you choose a NVA-participating provider, vision care benefits include a vision exam, standard lenses and a pair of frames once every 12 months. You and your covered spouse and dependents are eligible for the following benefits:

Co-payment
None

NVA Participating Provider

Non-Participating Provider

Examination

Once Every Plan Year

Covered 100%

Reimbursed Amount up to $35

Lenses

Once Every Plan Year

Single Vision
Bifocal
Trifocal
Lenticular
Progressives
Standard AR Coating
Premium AR Coating
Fashion Gradient Tint
High Index
Standard Scratch Coating
Solid Tints
UV Coatings
Photochromatic
Polycarbonates
Transitions
Blended Bifocal (Segment)

Standard Glass or Plastic
Covered 100%

Up to $40
Up to $50
Up to $75
Up to $100
Up to $76*
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A

Frames

Once Every Plan Year

Retail Allowance - Up to $190 (20% discount off balance)**

Up to $60

Contact Lenses

Once Every Plan Year

Elective Contact Lenses

Medically Necessary****

In lieu of Lenses & Frame

Up to $190 Retail¹ (15% discount (Conventional) or 10% discount (Disposable) off balance)***
Covered 100%

In lieu of Lenses & Frame

Up to $190
Up to $250

*Includes standard lens allowance
**Does not apply to Wal-Mart / Sam's Club locations
***Does not apply to Wal-Mart / Sam's Club or Contact Fill and the following locations: Target, Sears, JC Penney, Boscov's, Pearle, K-Mart, & Macys
****Pre-approval from NVA required

¹Additional professional services related to contact lenses (also known as fitting fees) would be included in the contact lens allowance shown above.

Lens options purchased from a participating NVA provider will be provided to the member at the amounts listed in the fixed option pricing list below:

$56 Polarized (Single Vision)*
$66 Polarized (Multi-Focal)*

*Polarized will be $75 at the following locations: Target, Sears, JC Penney, Boscov's, Pearle, K-Mart, & Macys

Options not listed will be priced by NVA providers at their reasonable & customary retail price less 20%.

Wal-Mart / Sam's Club Stores: Due to their everyday low prices Wal-Mart / Sam's Club will not provide the lens options at the fees listed in the fixed option pricing list. Wal-Mart / Sam's Club stores accept NVA for materials. Doctors affiliated with Wal-Mart / Sam's Club are not Wal-Mart / Sam's Club employees; therefore, participation for exams varies.


Vision Care
	What Is Covered
	What Is Not Covered
	When Coverage Ends
	When Coverage Ends for a Dependent Child

Related Forms
	NVA Vision Policy
	Claim Form for Non-Participating Providers
	Schedule of Vision Benefits
	EyeEssential Plan

Related Links
	National Vision Administrators

Disclaimer: Brandywine Benefits Online provides only an overview of your benefits from Brandywine School District and The State of Delaware. Brandywine School District and The State of Delaware reserve the right to amend or to terminate any benefit plan at any time, with or without notice. Review more important legal information about your benefits plans.