State of New Mexico Effective July 1, 2016

Plan Overview Eye Examination (Once every 12 months)

Covered in Full after $10 copay

Eyeglass Benefit Spectacle Lenses (Once every 12 months)

Covered in Full after $15 copay

Frame (Once every 24 months) Non-Collection Allowance

$150 retail allowance, plus 20% off overage /1 $200 retail allowance at Visionworks stores, plus 20% off overage /1

Davis Vision Exclusive Collection /2 (in lieu of allowance) - Fashion - Designer - Premier

Covered in Full Covered in Full Covered in Full

Contact Lens Benefit (in lieu of allowance) (Once every 12 months) Contact Lens Evaluation, Fitting & Follow-Up Non-Collection Contacts

$60 allowance, plus 15% off overage /1

Davis Vision Collection Contacts /2

Covered in Full after $15 copay

Contact Lenses Non-Collection Allowance

Up to $150 allowance plus 15% off overage /1

Davis Vision Collection Contacts /2 (in lieu of allowance) - Disposable - Planned Replacement

Covered in Full 8 boxes / multi-packs 4 boxes / multi-packs

Eye Examination: $40

Single-Vision Lenses: $40

Trifocal Lenses: $80

Elective Contacts: $105

Frame: $50

Bifocal / Progressive Lenses: $60

Lenticular Lenses: $100

Visually Required Contacts: $225

1/ Additional discounts not applicable at Costco, Sam’s Club or Walmart locations. 2/ Collection is available at participating independent provider offices and is subject to change.

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Frame Choice & Value

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7 out of 10 members pick from the Collection

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222 trendy and fashionable frames

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Fully-covered frames - up to $195 retail value

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Cost containment for both members & State of New Mexico

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Virtual Try-on-Tool available

The Davis Vision Exclusive Collection is provided in addition to plan’s in-network [$130] retail allowance.

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Eyeglass Lenses & Coatings Clear Plastic Lenses (all ranges of prescriptions & sizes)

Standard plastic material in single vision and lined bifocal or trifocal lens prescription

COVERED

Larger lenses for bigger frames

COVERED

Gradient or solid lens tinting in various colors

COVERED

Reduces risk of scratches

COVERED

Impact / shatter resistant lenses

$0* / $30

Provides protection from UVA / UVB rays

$12

Reduces internal / external reflection

$35

Reduces internal / external reflection plus they are easy-to-clean and more impact resistant

$48

Best anti-reflective benefits with the virtual elimination of reflections and glare

$60

No-line bifocal for everyday use

$50

Premium Progressives (Varilux®, etc.)

Provide a wider field of view in the distance and reading viewing areas

$90

Ultra Progressives (includes digital, free-form styles)

Exceptional comfort and enhanced visual clarity

$140

Thinner and lighter lenses

$55

Sunglass lenses that also reduce glare

$75

Lenses that darken in the sunlight

$65

Scratched lens replacement coverage

$20 / $40

Oversized Lenses Tinting of Plastic Lenses Scratch Resistant Coating Polycarbonate Lenses* Ultraviolet Coating Standard Anti-Reflective (AR) Coating Premium AR Coating Ultra AR Coating Standard Progressives

High-Index Lenses Polarized Lenses Plastic Photochromic Lenses (Transitions® Signature™) Scratch Protection Plan (single vision / multifocal)

*Polycarbonate lenses COVERED IN FULL for dependent children, monocular patients and patients with prescriptions +/- 6.00 diopters or greater.

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Contact Lenses

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$60 allowance and 15% off overage

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$150 retail allowance and 15% off overage

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Find A Better You At Visionworks

$200 •

Over 1,500 frames covered in full with enhanced $200 frame allowance only at Visionworks

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Offers that include 50% off additional pairs when you use your benefit

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700+ stores nationwide

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Frame Choice & Value

$10 $15

$65

FREE

$90

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Member Support

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Over 50,000 provider points of access including: - Independent optometrists & ophthalmologists - Retailers like Visionworks, Costco, Sam’s Club, Walmart and Eye Associates of New Mexico

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No claim forms for in-network services

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Member welcome kit with ID cards & local provider listing

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Secure member website to locate providers, check benefits and more

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Mobile App for iOS & Android

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Questions?

1 (800) 999-5431 and enter client code 7468

7468 • • • • • •

Benefit summaries Provider locator Online Exclusive Collection of frames Spanish language version available Brief educational videos Frame try-on tool

• Live support (Mountain Time): • Monday – Friday 6 a.m. – 9 p.m. • Saturday 7 a.m. – 2 p.m. • Sunday 10 a.m. – 2 p.m. • Automated service available 24 / 7

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