2020 Vision Benefit Summary
Your vision plan is administered by Custom Design Benefits, a Third Party Administrator.
Customer Service: (800) 598-2929 or (513) 598-2929 or visit our website at www.CustomDesignBenefits.com
Group Number: OAK00
| Eye Examination |
â—Ź One per Calendar Year
|
$10 Copay; Max Benefit Paid after Copay - $60 per exam |
| Eyeglass Lenses |
â—Ź One pair per calendar year
â—Ź Single Vision
â—Ź Bifocal
â—Ź Trifocal
â—Ź Lenticular
|
$25 Copay; Max Benefit Paid after Copay - $85 per pair
$25 Copay; Max Benefit Paid after Copay - $100 per pair
$25 Copay; Max Benefit Paid after Copay - $130 per pair
$25 Copay; Max Benefit Paid after Copay - $150 per pair
|
| Frames |
â—Ź One pair per 24 month period
|
$0 Copay; Max Benefit Paid after Copay - $120 per pair |
| Contact Lenses |
â—Ź One Pair per Calendar Year in Lieu of Eyeglasses
â—Ź Medically Necessary
â—Ź Not Medically Necessary, but required to correct visual acuity
|
$0 Copay; Max Benefit Paid after Copay - $225 per pair
$0 Copay; Max Benefit Paid after Copay - $140 per pair
|
| Contact Lens/Glasses Supplies |
â—Ź Cosmetic Contact Lenses
â—Ź Contact Solution
â—Ź Disposable Contact Lenses
â—Ź Contact Case
â—Ź Glasses Case
â—Ź Lens Cleaners
|
Not Covered |
| LASIK Surgery | Not Covered |
How to submit a claim:
Custom Design Benefits
Electronic Payer ID: 82056
5589 Cheviot Road
Cincinnati, Ohio 45247
(513) 598.2929 or (800) 598.2929
Fax: (513) 389.2998
claims@customdesignbenefits.com
This summary of benefits is provided to give you a general overview of the plan. We have attempted to make this summary as up to date and accurate as possible. However, if there are any discrepancies between the summary and the plan documents, the plan documents will supersede this summary. If you want more detail about your coverage and costs, please see the complete Summary Plan Description (SPD).