14 National Vision Administrators, L.L.C. www.e-nva.com Page 1 Your NVA Vision Benefit Summary Washington Suburban Sanitary Commission Group Number# 8735000001 Schedule of Vision Benefits www.e-nva.com How Your Vision Care Program Works Eligible members and dependents are entitled to receive a vision examination and one (1) pair of lenses once every calendar year and a frame once every two calendar years or contact lenses once every calendar year. (If you choose a frame, you will not be eligible for contact lenses for two calendar years) For your convenience, at the start of the program, you will receive two identification cards with participating providers in your zip code area listed on the back. At the time of your appointment, simply present your NVA identification card to the provider or indicate that your benefit is administered by NVA. The provider will contact NVA to verify eligibility. A vision claim form is not required at an NVA participating provider. Be sure to inform the provider of your medical history and any prescription or over-the-counter (OTC) medications you may be taking. To verify your benefit eligibility prior to calling or visiting your eye care provider, please visit our website at www.e-nva.com or contact NVA’s Customer Service Department toll-free at 1.800.672.7723 (TDD line 1-888- 820-2990) or NVA’s Interactive Voice Response (IVR). Customer Service is available 24 hours a day, 7 days a week, 365 days a year. Any question any time. If you are not a registered subscriber, you can still search our providers online by selecting the “Find a Provider” link on our home page. Enter group number 8735000001 or the group number on the identification card and enter in your search parameters. It’s that easy! *Does not apply to Contact Fill (NVA Mail Order) and may be prohibited by some manufacturers. **Pre-approval from NVA required. Provider will charge the difference between the wholesale cost and the plan allowance plus 20%. 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:  $10 Solid Tint $50 Progressive Lenses Standard*  $12 Fashion / Gradient Tint $65 Transitions Single Vision Standard  $10 Standard Scratch-Resistant Coating $70 Transitions Multi-Focal Standard  $12 Ultraviolet Coating $25 Polycarbonate (Single Vision)  $40 Standard Anti-Reflective $30 Polycarbonate (Multi-Focal)  $20 Glass Photogrey (Single Vision) $30 Blended Bifocal (Segment)  $30 Glass Photogrey (Multi-Focal) $55 High Index  $75 Polarized $100 Progressive Lenses Premium* *Fixed Pricing not available on certain brands Options not listed will be priced by NVA providers at their R&C retail price less 20%. In Maryland, members may be required to pay the full retail amount and not the negotiated discount amount at certain participating providers. Participating providers are not contractually obligated to offer sale prices in addition to outlined coverage. Regardless of medical or optical necessity, vision benefits are not available more frequently than specified in your policy. Get a Better View Benefit Frequency Participating Provider Non-Participating Provider Examination Once Every Calendar Year  Covered 100% Reimbursed Amount  Up to $64 (OD)  Up to $84 (MD) Lenses Once Every Calendar Year  Single Vision  Bifocal  Trifocal  Lenticular Standard Glass or Plastic  Covered 100%  Up to $50  Up to $90  Up to $110  Up to $310 Frame Once Every Two Calendar Years Wholesale Allowance  Up to $50  Up to $50 Contact Lenses Once Every Calendar Year Elective Contact Lenses Medically Necessary** In lieu of Lenses & Frame  Up to $100 Retail (25% discount off balance)*  Up to $600 In lieu of Lenses & Frame  Up to $100  Up to $600 National Vision Administrators, L.L.C. Your NVA Vision Benefit Summary Schedule of Vision Benefits