Vision Benefit Plan Certificate of Coverage. Vision Benefit Web Site: WAYNE COUNTY COMMUNITY WAYNE COUNTY

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1 Vision Benefit Plan Certificate of Coverage Vision Benefit Web Site: U WAYNE COUNTY COMMUNITY COLLEGE DISTRICT COLLEGE WAYNE COUNTY COMMUNITY

WELCOME TO HERITAGE VISION PLANS page 2 SECTION I TRUST PLAN BENEFITS Table of Contents WELCOME TO Scope HERITAGE of Coverage VISION PLANS page 32 What's Not Covered page 4 WELCOME TO HERITAGE VISION

2 WELCOME TO HERITAGE VISION PLANS page 2 SECTION I TRUST PLAN BENEFITS Table of Contents WELCOME TO Scope HERITAGE of Coverage VISION PLANS page 32 What's Not Covered page 4 WELCOME TO HERITAGE VISION PLANS page 2 SECTION I TRUST PLAN WELCOME TO BENEFITS HERITAGE VISION PLANS page 2 SECTION WELCOME I TO Scope TRUST HERITAGE of PLAN Coverage VISION PLANS page 3 2 BENEFITS SECTION What's WAYNE Not COUNTY Covered COMMUNITY page 4 WELCOME SECTION I TO Scope COLLEGE TRUST HERITAGE of PLAN Coverage VISION PLANS page 32 DISTRICT BENEFITS What's BENEFITS Not Covered page 4 Scope of Coverage page 3 SECTION WELCOME I TO Scope TRUST HERITAGE of PLAN Coverage VISION PLANS page 32 What's Not Covered page 4 What's BENEFITS Not Covered page 4 SECTION I Scope TRUST of PLAN Coverage page 3 SECTION II What's BENEFITS USING Not YOUR Covered BENEFIT PLAN page 4 FREQUENTLY Using a Network Provider page 5 Scope ASKED of Coverage QUESTIONS page What's Claims Appeals Not Covered page 6 page 4 GLOSSARY Unresolved OF EYEWEAR Concerns TERMS page 6 Different Types of Prescription Lenses page 10 FREQUENTLY ASKED QUESTIONS page Eyeglass Lens Materials page 11 FREQUENTLY Eyeglass ASKED Lens QUESTIONS Coatings and Options page GLOSSARY WEB SITE: HOW OF EYEWEAR TO USE TERMS page 9 GLOSSARY FREQUENTLY MEMBER RIGHTS/PRIVACY OF Different ASKED EYEWEAR Types QUESTIONS of TERMS Prescription PRACTICES Lenses page SECTION III PROVIDER DIRECTORY page Eyeglass Lens Materials page 11 Different Types of Prescription Lenses page 10 GLOSSARY FREQUENTLY NOTES/APPOINTMENTS Eyeglass ASKED Lens QUESTIONS Coatings and Options page MEMBER RIGHTS/PRIVACY OF EYEWEAR TERMS Eyeglass Lens Materials PRACTICES page 116 Eyeglass Different Types Lens Coatings of Prescription and Options Lenses page GLOSSARY FREQUENTLY MEMBER RIGHTS/PRIVACY OF ASKED EYEWEAR QUESTIONS TERMS PRACTICES page GLOSSARY OF Eyeglass EYEWEAR Lens Materials TERMS page 11 MEMBER RIGHTS/PRIVACY Different Types of Prescription PRACTICES Lenses NOTES/APPOINTMENTS Eyeglass Lens Coatings and Options page GLOSSARY OF Different EYEWEAR Types of TERMS Prescription Lenses page 17 Eyeglass Lens Materials page 11 Eyeglass Lens Materials page 18 NOTES/APPOINTMENTS MEMBER RIGHTS/PRIVACY Eyeglass Different Types Lens Coatings of Prescription PRACTICES and Options Lenses page Eyeglass Lens Coatings and Options page 19 Eyeglass Lens Materials page 11 MEMBER NOTES/APPOINTMENTS RIGHTS/PRIVACY Eyeglass Lens Coatings PRACTICES and Options page NOTES/APPOINTMENTS MEMBER RIGHTS/PRIVACY PRACTICES NOTES/APPOINTMENTS page page page 14 Heritage Vision Plans 1

3 Introduction WELCOME Wayne Cty Community College District Employees! We are glad to have you as members of the Heritage Vision Plans family. Heritage is a vision benefit management company that is dedicated to providing exceptional service, world-class quality and an extensive provider network. Heritage is committed to the quality, reliability and service excellence that have made us successful since Our goal is to provide you with the best in eye care and service. We are providing this booklet to enable you and covered dependents to make the best possible use of valuable vision care benefit. If you have questions that are not answered here, please call us toll-free at , or us at corporate@heritagevisionplans.com. Cordially, George P. Barnes, Jr. President Heritage Vision Plans Heritage Vision Plans has developed this guide to help you receive maximum value from vision benefit. This handbook covers important topics such as: what services are covered, accessing a provider, filing a claim, and member rights and privacy practices. Heritage Vision OpticalPlans 2

WAYNE COUNTY COMMUNITY COLLEGE DISTRICT FORD MOTOR - VISION COMPANY BENEFIT BENEFIT PLAN PLAN Eligibility Scope of Coverage ( Your SAMPLE eligibility COMPANY and/or ) BENEFIT dependent(s) PLAN

4 WAYNE COUNTY COMMUNITY COLLEGE DISTRICT FORD MOTOR - VISION COMPANY BENEFIT BENEFIT PLAN PLAN Eligibility Scope of Coverage ( Your SAMPLE eligibility COMPANY and/or ) BENEFIT dependent(s) PLAN eligibility to par- ( SAMPLE COMPANY BENEFIT PLAN Your SEIU Scope LOCAL of Coverage 79 STAFF ) is determined PLAN ticipate in this Plan is determined by Ford Wayne Motor by County (Sample Company. Community Company). Scope College of Coverage This District. section of the Vision Benefit Handbook will Scope explain of Coverage plan benefit. The following chart Scope of Coverage Your Scope of of Coverage is determined is by Ford. by (Sample This indicates Scope what of services Coverage are is covered, determined how by often (Sample the Covered each Company). section Your Scope of the of This Coverage Vision section Benefit of is determined the Handbook Vision Benefit by will Wayne explain Handbook County covered Company). Group. This service This section can section of the be of the Vision used, what Vision Benefit you Benefit Handbook can expect Handbook will to will Community plan explain benefit. College The plan District. following benefit. This chart section The indicates following of the what Vision pay when receiving services from an in-network provider chart Benwill explain explain plan plan benefit. benefit. The following The following chart chart indicates and indicates services efit Handbook are what what covered, will services explain how reimbursement are often covered, plan each benefit. amounts how covered will often The service be when each following indicates what services what are services covered, are covered, how often how each often covered each service can be used, can and be what used, you what can you expect can to expect pay when to receiving covered can chart be indicates used, service what what services can you services can from be expect an used, are covered, out-of-network what to pay you how when can often receiving provider. expect each to pay services covered when from service receiving an can in-network services be used, provider from what an you in-network and can what expect provider to pay pay receiving when services receiving from services an in-network from an in-network provider. provider and reimbursement when what receiving services amounts reimbursement from will an be amounts in-network when receiving will provider. be when and what reimbursement amounts will be when receiving services from services an out-of-network from an out-of-network provider. provider. receiving services from an out-of-network provider. COVERAGE SERVICES FREQUENCY Section I IN-NETWORK: COVERAGE Comprehensive Eye Exam For Eyeglasses (Does not apply to Contact Lens Exam) Frames Lenses: (Choice of One) Single Vision Bifocal Trifocal Lenticular Lens Options: Tint (Therapeutic Rose Tint #1 or #2) Once every 24 months (from date of last exam) Once every 24 months (from date of last purchase) Once every 24 months (from date of last purchase) Once every 24 months (from date of last purchase) Once every 24 months (from date of last purchase) Once every 24 months (from date of last purchase) Once every 24 months (from date of last purchase) Fully Covered, No Co-pay Covered up to a $125 maximum Fully Covered, No Co-pay Fully Covered, No Co-pay Fully Covered, No Co-pay Fully Covered, No Co-pay Fully Covered, No Co-pay Frame Warranty (1 year manufacturer s) Once every 24 months (from date of last purchase) OR Fully Covered, No Co-pay Contact Lenses - $ Allowance towards Exam and Contact Lenses Comprehensive Eye Exam Contact Exam and Fitting: For Contact Lenses 1 Once every 24 months (from date of last purchase) Covered up to a (Applies to Contact Lens Exam and Fitting) $64.50 maximum eritage ge Vision Optical Plans 3 1 Contacts Lenses 1 Contact Lenses: Once every 24 months You are eligible for contact lenses OR glasses, not both, in any 12 month consecutive period. (includes 1 You are 2 disposables) (from date of last purchase) Covered up to a eligible Designated for contact locations lenses can OR be found glasses, at not both, in any benefit $64.50 maximum period. eritage Vision Plans 3 e 1 You are eligible for contact lenses OR glasses, not both, in any 24 Month Consecutive 3 Period. Heritage Vision Plans 3

What s Not Covered Products and services not covered under the plan include: Non-prescription lenses Two pairs of glasses instead of bifocals Lenses and frames furnished under a plan, that are lost

5 What s Not Covered Products and services not covered under the plan include: Non-prescription lenses Two pairs of glasses instead of bifocals Lenses and frames furnished under a plan, that are lost or destroyed Parts or repair of frame not covered under manufacturers' warranty Medical or surgical treatment of the eyes Drugs or medications Corrective vision services, treatments, and materials of an experimental nature Services not visually necessary Industrial (3mm) safety lenses and safety frames with side shields Any services not specified in the Wayne County Community College District Scope of Coverage Heritage Optical Vision Plans 4

Section II USING YOUR BENEFIT PLAN Using a Network Provider Here are the steps to take: 1. Select a doctor from the list of network providers. The list can be accessed on our Web site: www.

6 Section II USING YOUR BENEFIT PLAN Using a Network Provider Here are the steps to take: 1. Select a doctor from the list of network providers. The list can be accessed on our Web site: or by calling our Interactive Voice Response (IVR) System toll-free at: The Interactive Voice Response System is available seven days a week, 24 hours a day. 2. Make an appointment with the doctor of choice. When calling to make an appointment, identify self as a WCCCD Employee and a Heritage Vision Plans Member. The Provider will ask for ID Number (member's SSN) and (the patient's) Date of Birth. As a Heritage Vision Plans member, you will maximize benefits and reduce out-of-pocket costs by choosing to visit an In-Network Provider. 3. The Doctor / Provider will verify eligibility and/or eligibility of dependents. 4. When the examination is complete and you and/or dependents have been fitted for any necessary glasses or contact lenses, the doctor will explain any additional charges that you may have to pay. 5. The Doctor / Provider will take care of all the paperwork. There are no claim forms for you to complete. Heritage Vision OpticalPlans 5

7 Claims Appeals / Unresolved Concerns 6. Claims Appeals If a claim is denied, in whole or in part, Heritage will notify you of the reasons for denial. Within 60 days after the date of the denial notice, you may make a written request for review of the denial. The request must include any and all supporting documentation. The claim will be reviewed and you will be notified of the decision. Submit claim appeals to: Heritage Vision Plans, Inc. ATTN: Claims Appeal Manager 440 E. Congress, Suite 300 Detroit, MI Unresolved Concerns If you are not satisfied with Heritage Vision Plans' resolution of any customer service issue you may have, please contact Human Resources Department representative. After exhausting all avenues to have concerns satisfactorily addressed, you may contact: Health Plans Division Office of Financial and Insurance Regulation 611 W. Ottawa, Third Floor P.O. Box Lansing, MI Heritage Vision Plans 7 Heritage Vision Plans 6

FAQ FREQUENTLY FREQUENTLY ASKED ASKED QUESTIONS QUESTIONS Q: Q: Do Do I need need an an ID ID card? card? A: A: Yes, No, you you do will not use need an Blue ID Cross card.

8 FAQ FREQUENTLY FREQUENTLY ASKED ASKED QUESTIONS QUESTIONS Q: Q: Do Do I need need an an ID ID card? card? A: A: Yes, No, you you do will not use need an Blue ID Cross card. Blue When Shield you of call Michigan for an appointment ID card. When with a you provider, call f or the an provider appointment will verify with a provider, eligibility. the The providerwill provider v will erify ask for eligibility. Member The provider ID number will which ask for is Member Social ID Security number Number. and (Patient's) Date of Birth. Q: Q: How How can can I obtain obtain a list list of of vision vision care care providers providers in in network? network? A: A: Heritage Heritage Vision Vision Plans Plans offers offers a provider provider locator locator on on our our Web Web site: site: and and by by calling calling our our toll-free toll-free number: number: Q: Q: Where Where do do I get get a claim claim form form to to submit submit for for reimbursement? reimbursement? A: A: If There you is visit no an claim in-network form to provider, submit. When there you is no visit claim the form Heritage to submit. network The provider, provider the will provider handle will all of handle the paperwork all of the paper and work will submit and will the submit claim. the If you claim. visit an out-of-network provider, you must get an itemized Q: Do receipt all from optical the provider locations and submit have that the receipt same to frames Heritage to Vision choose Plans from? for reimbursement. The A: receipt No, the will frames serve will as differ the claim by location, form. Please but each see location will 6 have for a a complete wide variety description of styles to of choose what the from. Page itemized receipt must contain. Q: Where do I send my itemized receipt for reimbursement? A: Send the itemized receipt to: Heritage Vision Plans ATTN: Vision Claims Reimbursement Livernois Avenue, Suite B Detroit, MI Heritage Vision Plans 7

Q: Do all optical locations have the same frames to choose from? A: No, the frames will differ by location, but each location will have a wide variety of styles to choose from.

9 Q: Do all optical locations have the same frames to choose from? A: No, the frames will differ by location, but each location will have a wide variety of styles to choose from. FAQ continued Q: How can my current doctor join the network? A: You may refer doctor to us for inclusion in our network. Request that doctor contact our Q: Can I get both contact lenses and glasses? Director of Provider Relations at A: You are eligible to receive contact lenses OR glasses, not both, in the same Plan Year as a covered ext for an application packet, or us at corporate@heritagevisionplans.com benefit. Q: How can my current doctor join the Q: Is Lasik a covered or partially covered benefit? network? A: Lasik is not a covered or partially covered benefit A: You may refer doctor to us for inclusion in our under the Wayne County Community College Disnetwork. Request that doctor contact our Director trict Scope of of Provider Coverage. Relations at ext for an application packet, or Q: How do us I know at corporate@heritagevisionplans.com which of the toll-free numbers listed in this book to use? Q: A: Can If you I get need both information contact lenses regarding and eligibility glasses? or A: You provider are eligible locations, to receive use the contact lenses OR glasses free in number. the same This Plan will Year connect as a you covered to the benefit. Customer If toll you Service wish Center to purchase or IVR both system. in the same Plan Year, you may receive a preferred pricing discount on the non-covered For all other item. member service needs, please use the toll free number. This will connect Q: Is Lasik a covered or partially covered benefit? you to Heritage Vision Plans' administrative offices. A: Lasik is not a covered or partially covered benefit under the MPS Group's Scope of Coverage. Q: How do I know which of the toll-free numbers listed in this book to use? A: If you need information regarding eligibility or provider locations, use the toll free number. This will connect you to the Customer Service Center or IVR system. For all other member service needs, please use the toll free number. This will connect you to Heritage Vision Plans' administrative offices. Heritage Vision OpticalPlans 89

Heritage Web Site: How To Use Step 1: Step 2: Step 3: Go to the Heritage Vision Plans Website The Heritage Vision Plans Web site is www.heritagevisionplans.

10 Heritage Web Site: How To Use Step 1: Step 2: Step 3: Go to the Heritage Vision Plans Website The Heritage Vision Plans Web site is Select Member Login Click the "member login" button in the upper right corner of the web page (see example below). Login At the secure login screen, enter the Primary Member's 9-digit Social Security Number (SSN) and the Primary Member's Date of Birth. After logging in, you will have full member access to eligibility information, the Provider Search Engine, and the WCCCD vision benefit information. Please note the log-in is sensitive to entry format. All ID dashes (-) and date slashes (/) need to be entered like the example below. >9-digit ID Number: (SSN Format) xxx-xx-xxxx >Date of Birth: mm/dd/yyyy (Snapshot of Home Page) C Click the Click member the member login Button login Button Heritage Optical 5 Heritage Vision Plans Heritage Vision Plans 9

11 Section III Wayne County Community Instaset Plastic Corporation College District Provider Directory Provider Directory Participating Provider information is subject to change without notice. Please call Providers, listed in this Directory, to verify their continued participation in the Heritage Provider Network, prior to scheduling appointment or receiving services. The Heritage Vision Plans Web site ( or toll-free Automated Provider Locator ( ) will always be source for the most up-to-date Participating Provider Directory for vision care plan Heritage Optical Vision Plans

12 ALLEN PARK Natalie M. Sorce O.D. Matthew S. Haubert O.D Outer Drive Allen Park, MI (313) AUBURN HILLS Fortney Eyecare Associates William J. Fortney O.D. Christine A. Jack O.D. Alicia T. Zimnicki O.D Walton Boulevard Auburn Hills, MI (248) Pontiac Eye Clinic Michael Weishaus O.D. Randall M. Weishaus O.D. Max Gottesman O.D. Lorne M. Gottesman O.D Baldwin Road Auburn Hills, MI (248) BATTLE CREEK Gerald E. Hanna O.D. 65 E. Columbia Avenue Battle Creek, MI (269) BELLEVILLE Belleville Vision Center Barry K. Lesnick O.D Belleville Road Belleville, MI (734) BENTON HARBOR Karl K. Damm O.D S. M-139 Benton Harbor, MI (269) BRIGHTON Pearle Vision (Formerly D.O.C) Randy Watsky O.D W. Grandriver Brighton, MI (810) BROWNSTOWN Redford Optical Jennifer A. Ciak O.D West Road Brownstown, MI (734) CANTON Pearle Vision (Formerly D.O.C) Jeffrey S. Hagan O.D Ford Road Canton, MI (734) Visionpro Eyecare Barry K. Lesnick O.D N. Canton Center Road Canton, MI (734) Elite Eyecare Center Daniel J. Trainor O.D. Andrew H. Schmitzer O.D Ford Road Canton, MI (734) Sharper Vision Jacquelyn Blakey O.D Canton Center Road Canton, MI (734) CHARLOTTE Linda L. Goeman-Stahl O.D Lansing Road Suite B Charlotte, MI (517) CHESTERFIELD Pearle Vision (Formerly D.O.C) Arlene Barton O.D. Michael Weisberger O.D Mile Road Chesterfield, MI (586) CLAWSON House Of Optical Mark J. Simard O.D. Robert R. Feldman O.D. 329 W. 14 Mile Road Clawson, MI (248) CLINTON TWNSHP Metro Vision II Gerald J. Blazius O.D Garfield Road Clinton Township, MI (586) COLDWATER Joseph M. Hibler O.D. Gerald E. Hanna O.D. 755 E. Chicago Street Coldwater, MI (517) DEARBORN Fortney Eyecare Associates William J. Fortney O.D. Christine A. Jack O.D. Alicia T. Zimnicki O.D Michigan Avenue Dearborn, MI (313) William C. McIntyre O.D Michigan Avenue Dearborn, MI (313) Tatjana Ratzenberger O.D Hubbard Drive, 2 nd Floor Dearborn, MI (313) Midwestern Vision Center Howard J. Rosner O.D Schaefer Road Dearborn, MI (313) DEARBORN HTS. Redford Optical Jennifer A. Ciak O.D Ford Road Dearborn Heights, MI (313) DETROIT Heritage Optical Center Robert Kocembo O.D. Michael J. Lowe O.D Livernois Avenue Detroit, MI (313) Heritage Optical Center Robert Kocembo O.D. 87 Monroe Street Detroit, MI (313) Heritage Optical Center Robert Kocembo O.D E. Jefferson Avenue Detroit, MI (313) Black & White Look Optical Myron J. Gerber O.D E. Jefferson Suite A Detroit, MI (313) Ayaz M. Khan O.D. Henry Ford Hospital 2799 W. Grand Blvd, 1 st Floor Detroit, MI (313) Timothy J. Guthrie O.D W. Outer Drive, 1 st Floor Detroit, MI (313) Health Center Optical Robert F. Lee O.D Saint Antoine Street Detroit, MI (313) Belmont Vision Lowell Ressler O.D E. 8 Mile Road Detroit, MI (313) Optical World Michael Weishaus O.D. Randall M. Weishaus O.D. Max Gottesman O.D. Lorne M. Gottesman O.D Grand River Ave Detroit, MI (313) Rosedale Eye Care Seymour R. Rosen O.D Grand River Avenue Detroit, MI (313) Murray A. Feldman O.D Michigan Avenue Detroit, MI (313) Heritage Vision Plans 11

13 EASTPOINTE Normandy Optical Gerald J. Blazius O.D. Mark J. Simard O.D Gratiot Avenue Eastpointe, MI (586) GARDEN CITY Elite Eyecare Centers Andrew H. Schmitzer O.D. Daniel J. Trainor O.D Inkster Road Suite 303 Garden City, MI (734) Eye Works Optical Angelo Tocco O.D Mack Avenue (inside Grosse Pointe Eye Ctr.) Grosse Pointe Wds, MI (313) HASTINGS JONESVILLE Joseph M. Hibler O.D. Matthew S. Haubert O.D. 855 Olds Street Jonesville, MI (517) W. Fraser Vipond M.D. & Oxford Optical Gratiot Avenue Eastpointe, MI (586) FARMINGTON HLS. Barry A. Bell O.D. Anna M. Santillan O.D. Rovetta M. Mattia O.D W. 10 Mile Road Farmington Hills, MI (248) FLINT Riverfront Optical Scott McDowell O.D. Marla Hayden O.D. G-4325 Miller Road Flint, MI (810) Riverfront Optical Francis Stone O.D. Marla Hayden O.D Davison Road Flint, MI (810) FORT GRATIOT Charles G. Shermetaro O.D. Kimberly A. Sebok O.D th Avenue, Suite 5 Fort Gratiot, MI (810) FRASER Fraser Optical Inc. Aimee K. Gray O.D. James G. Miller O.D. Mark A. Stefani O.D. Michael J. Sistick O.D Groesbeck Hwy. Fraser, MI (586) GRAND HAVEN Christine I Vandeweghe OD Amy L. Fitzgibbon O.D S. Beacon Boulevard Grand Haven, MI (616) GRAND RAPIDS Anthony W. Danko O.D. David G. Higley O.D Northland Drive NE Grand Rapids, MI (616) Sherah J. Eavey O.D th Street SE Grand Rapids, MI (616) Sherah J. Eavey O.D Plainfield Avenue NE Grand Rapids, MI (616) Martha Romanyk O.D Cascade Road Grand Rapids, MI (616) GRANDVILLE Amy L. Fitzgibbon O.D. Michael P. Jacquemin O.D Wilson Avenue SW Grandville, MI (616) GROSSE POINTE MM AAT TERR E IIAAL I LLS S OO NNL LLY Y Henry Ford Medical Center E. Jefferson, 1 st Floor Grosse Pointe Park, MI (313) Heidi M. Gordon O.D. 803 W. State Street Hastings, MI (269) HOLLAND Robert P. Arens O.D. Michael P. Jacquemin O.D. David G. Higley O.D S. Washington Avenue Holland, MI (616) Michael P. Jacquemin O.D. David G. Higley O.D. Amy L. Fitzgibbon O.D. Martha Romanyk O.D Riley Street Holland, MI (616) IONIA Paul T. Lang O.D S. State Street Ionia, MI (616) JACKSON Linda L. Goeman-Stahl O.D E. Michigan Avenue Jackson, MI (517) Linda L. Goeman-Stahl O.D N. West Avenue Jackson, MI (517) JENISON Stacy L. Maier O.D. Sherah J. Eavey O.D. 304 Baldwin Avenue Jenison, MI (616) KALAMAZOO Gerald E. Hanna O.D S. Park Street Kalamazoo, MI (269) Aaron J. Whitsett O.D Gull Road Kalamazoo, MI (269) Aaron J. Whitsett O.D. Gerald E. Hanna O.D. 125 S. Kalamazoo Mall Kalamazoo, MI (616) Aaron J. Whitsett O.D. Karl K. Damm O.D. Kristina Swartz O.D. David C. McClintic O.D W. Main Street Kalamazoo, MI (269) Aaron J. Whitsett O.D. 601 John Street Suite 261 Kalamazoo, MI (269) KENTWOOD Amy L. Fitzgibbon O.D th Street SE Kentwood, MI (616) LAKE ORION Stephanie B. Turpen O.D. 684 S. Lapeer Road Lake Orion, MI (248) Heritage Vision Plans 12

14 LANSING Pearle Vision (Formerly D.O.C) Marvin Matson O.D S. Cedar Street Lansing, MI (517) Paul T. Lang O.D. Leslie K. Delemeester O.D W. Saginaw Hwy. Lansing, MI (517) Optiview Vision Center Jack Adkins O.D. 635 S. Waverly Road Suite B Lansing, MI (517) LIVONIA Fortney Eyecare Associates William J. Fortney O.D. Christine A. Jack O.D. Alicia T. Zimnicki O.D W. 5 Mile Road Livonia, MI (734) Royal Optics Gary S. Yee O.D Plymouth Road Livonia, MI (734) Pearle Vision (Formerly D.O.C) Howard J. Rosner O.D Six Mile Road Livonia, MI (734) Michigan Eyecare Institute Kevin J. Trapp O.D Levan Livonia, MI (734) MADISON HEIGHTS Kurt M. Schulz O.D John R Road Madison Heights, MI (248) MILFORD Fariba M. Hickinson O.D. Anna Santillan O.D. 516 Highland Avenue Milford, MI (248) MONROE Best Vision / Eyecare One Douglas W. Baltrip O.D. Kristy L. Watson O.D. 504 N. Telegraph Road Monroe, MI (734) MUSKEGON Ronald T. McClatchey O.D. Christine I Vandeweghe OD 2159 E. Apple Avenue Muskegon, MI (231) Ronald T. McClatchey O.D. David G. Higley O.D E. Sternberg Road Muskegon, MI (231) NILES Karl K. Damm O.D. Matthew S. Haubert O.D S. 11th Street Niles, MI (269) OKEMOS Leslie K. Delemeester O.D W. Grand River Avenue Okemos, MI (517) OSCODA Fraser Optical Inc. Aimee K. Gray O.D. James G. Miller O.D. Mark A. Stefani O.D. 211 N. State Street Oscoda, MI (989) OWOSSO Robert C. Hagemann O.D. Howard Foote O.D E. Main Street Owosso, MI (989) PLAINWELL Michael P. Jacquemin O.D. Robert P. Arens O.D. Heidi M. Gordon O.D. Aaron J. Whitsett O.D West M-89 Plainwell, MI (269) PONTIAC Lynn Optical Associates Samuel M. Wapner O.D. 22 N. Telegraph Road Pontiac, MI (248) Optiview Vision Center Angela Iceberg O.D. Frank Kozin O.D. 41 E. Walton Boulevard Pontiac, MI (248) PORTAGE David C. McClintic O.D S. Westnedge Avenue Portage, MI (269) RICHMOND Fraser Optical Inc. Aimee K. Gray O.D. James G. Miller O.D. Mark A. Stefani O.D. Michael J. Sistick O.D Gratiot Richmond, MI (586) ROCHESTER HILLS Pearle Vision (Formerly D.O.C) John Gedda O.D. Spring Hill Plaza 2915 Walton Boulevard Rochester Hills, MI (248) Accent Eyecare (Optometry On The Mall) Johnny Leung O.D S. Rochester Road Rochester Hills, MI (248) ROCKFORD Anthony W. Danko O.D. Martha Romanyk O.D. 507 E. Division Street Rockford, MI (616) ROMEO Fraser Optical Inc. Aimee K. Gray O.D. James G. Miller O.D. Mark A. Stefani O.D N. Van Dyke Road Romeo, MI (586) ROSEVILLE Amy F. Jones O.D. Gregory C. Herbart O.D. Kristi A. Watchorn O.D. Ranald F. MacKenzie O.D. Xanthi Tuchowski O.D. Roseville Super Vision Center Gratiot Avenue Roseville, MI (586) ST. CLAIR Distinctive Eyewear Gary Kendrick O.D Clinton Avenue Saint Clair, MI (810) ST. CLAIR SHORES Shore Optical Mark Lavine O.D Harper Avenue St Clair Shores, MI (586) ST. JOSEPH Andrea L. Bowmar O.D. Kristina R. Swartz O.D Washington Avenue St Joseph, MI (269) Heritage Vision Plans 13

15 SAGINAW Riverfront Optical Raymond Lalonde O.D. Paul Golsch O.D. Melissa David O.D S. Cabaret Trail Saginaw, MI (989) SHELBY TOWNSHIP Pearle Vision (Formerly D.O.C) Jerry Lebeau O.D Van Dyke Avenue Shelby Township, MI (586) Fraser Optical Inc. Aimee K. Gray O.D. James G. Miller O.D. Mark A. Stefani O.D Van Dyke Ave Shelby Township, MI (586) SOUTH LYON Oakland Vision Fred E. Weiser O.D. 608 N. Lafayette Street South Lyon, MI (248) SOUTHFIELD Pearle Vision (Formerly D.O.C) Kenneth Foon O.D. (inside Northland Mall) Northwestern Hwy. Southfield, MI (248) Black & White Look Optical Myron J. Gerber O.D W. Ten Mile Road Southfield, MI (248) Benjamin H Stein O.D. Edward F. Stein O.D Northwestern Hwy #635 Southield, MI (248) Frances Ceritano O.D Southfield Road Southfield, MI (248) Michigan Eyecare Institute Kevin J. Trapp O.D Telegraph Road Ste 100 Southfield, MI (248) Advance Eye Care M.D. Lanny Green M.D Greenfield Road Ste 144 Southfield, MI (248) SOUTHGATE Lesnick Optical Barry K. Lesnick O.D Fort Street Southgate, MI (734) Natalie M. Sorce O.D. Matthew S. Haubert O.D Eureka Road Southgate, MI (734) Nathan D. Harris O.D. Shanna M. Voss O.D. Southgate Super Vision Center Eureka Road Southgate, MI (734) STERLING HEIGHTS Tatjana Ratzenberger O.D. William K. Carter O.D. Daniel L. Flick O.D. Lakeside Super Vision Center Schoenherr Road Sterling Heights, MI (586) Larry T. Olson O.D. Henry Ford Medical Center Mile Road, 2 nd Floor Sterling Heights, MI (586) Fraser Optical Inc. Aimee K. Gray O.D. James G. Miller O.D. Mark A. Stefani O.D. Michael J. Sistick O.D Mile Road Sterling Heights, MI (586) STURGIS Mark Prieur O.D. 500 S. Centerville Road Sturgis, MI (269) TAYLOR Optiview Vision Center Frank Kozin O.D S. Telegraph Road Taylor, MI (313) Oakland Eyewear MM AAT TERR E IIAAL I LLS S OO NNL LLY Y Plaza South Drive Taylor, MI (734) THREE RIVERS Mark Prieur O.D. 111 S. US Hwy-131 Three Rivers, MI (269) TROY Golden Gate Optical Asher L. Weisman O.D. Robert E. Brinker O.D E. Big Beaver Road Troy, MI (248) WALKER David G. Higley O.D. Aaron D. Miller O.D Lake Michigan Drive Walker, MI (616) David G. Higley O.D. Sherah J. Eavey O.D Alpine Avenue NW Walker, MI (616) WALLED LAKE Oakland Vision Centers Fred E. Weiser O.D. 519 N. Pontiac Trail Walled Lake, MI (248) WARREN Pearle Vision (Formerly D.O.C) Anthony D. Spitler O.D Dequindre Road Warren, MI (586) Fortney Eyecare Associates William J. Fortney O.D. Christine A. Jack O.D. Alicia T. Zimnicki O.D Mile Road Warren, MI (586) WATERFORD Pearle Vision (Formerly D.O.C) Bradley D. Goldberg O.D Highland Road Waterford, MI (248) WEST BLOOMFIELD Robert V. Finlay O.D. Barry A. Bell O.D. Curtis E. Wee O.D. Rovetta Mattia O.D. W. Bloomfield Super Vision Ctr Farmington West Bloomfield, MI (248) WESTLAND Fortney Eyecare Associates William J. Fortney O.D. Christine A. Jack O.D. Alicia T. Zimnicki O.D Warren Avenue Westland, MI (734) Jay P. Lizyness O.D. Robert C. Hagemann O.D. Emily S. Michalik O.D. Margaret M. Kuznicki O.D. Bruce R. Wolffis O.D. Westland Super Vision Center Central City Parkway Westland, MI (734) WOODHAVEN Matthew S. Haubert O.D Allen Road Woodhaven, MI (734) Heritage Vision Plans 14

16 WYANDOTTE Wyandotte Optical Dan Stein O.D Biddle Avenue Wyandotte, MI (734) WYOMING Stacy L. Maier O.D th Street SW Wyoming, MI (616) YPSILANTI Fortney Eyecare Associates William J. Fortney O.D. Christine A. Jack O.D. Alicia T. Zimnicki O.D. 2 N. Huron Street Ypsilanti, MI (734) Heritage Vision Plans 15

17 Member Rights and Responsibilities/ Privacy Practices If you would like to request a copy of our Member Rights and/or Notice of Privacy Practices, please contact us at: Plan Administrator Heritage Vision Plans, Inc. 440 E. Congress, Suite 300 Detroit, MI Phone: (888) Fax: (313) corporate@heritagevisionplans.com Member Rights and Responsibilties Members may be required to cooperate in the subrogation and coordination of benefits. Benefits may not be assigned. Members shall notify their employer in case of address change. Members shall have the right to inspect and review their own medical records Provider Information Information about any participating provider is available from Heritage Vision Plans at the above listed address. Non-Discrimination Heritage Vision Plans does not discriminate on the basis of race, color, creed, national origin, residence within the approved service area, lawful occupation, sex, handicap, or marital status. Heritage Vision OpticalPlans 16

Glossary of Eyewear Terms The The Eyewear Eyewear Terms Terms in in this this Glossary Glossary are are provided provided for for informational informational purposes purposes only.

18 Glossary of Eyewear Terms The The Eyewear Eyewear Terms Terms in in this this Glossary Glossary are are provided provided for for informational informational purposes purposes only. only. They They are are not not meant meant to to reflect reflect actual actual covered covered benefits benefits under under vision vision plan. plan. Please Please refer refer to to page page 3, 3 of of this this Handbook, Handbook for for covered covered benefits. benefits. DIFFERENT TYPES OF PRESCRIPTION LENSES Based upon the particular eyesight disorder, different types of corrective lenses are prescribed. As a rule, there are 4 types of prescription lenses: Single Vision, Bifocal, Trifocal, and Progressive. Single Vision Lenses Single Vision lenses have only one viewing area throughout the lens. This corrected area can be for far distance, near distance, or reading. Bifocal Lenses Bifocals (meaning a lens with two points of focus, usually one for distance and one for near) are some of the most commonly prescribed multi-focal lenses. A small portion of the bifocal eyeglass lens is reserved for the near-vision correction. The rest of the lens is usually a distance correction, but may have no correction at all if the wearer has good distance vision. Trifocal Lenses Trifocal lenses are lenses with three points of focus: usually for distance, intermediate and near. Trifocals have an added segment above the bifocal for viewing things in the intermediate zone: about an arm's length away. Computer terminals are typically in the intermediate zone. Progressive Lenses Progressive lenses correct vision for multiple distances without the visible segment lines seen in bifocal or trifocal lenses. Instead they have a graduated section in which the power of the lens progresses smoothly from one prescription to the other, allowing the wearer to see clearly at all distances. Heritage Vision Plans 28 Heritage Vision Plans 177

Glossary of Eyewear Terms (continued) EYEGLASS LENS MATERIALS Choosing the right lens material for eyeglasses is an important decision, and there are several options.

19 Glossary of Eyewear Terms (continued) EYEGLASS LENS MATERIALS Choosing the right lens material for eyeglasses is an important decision, and there are several options. Plastic Lenses Plastic remains the most popular lens material for eyeglasses in the United States, accounting for nearly 50% of all lenses sold. Plastic is generally regarded as the economy choice in lenses. It offers good optical clarity at a lower price point. Due to thickness, it is not typically recommended for higher prescription powers. Polycarbonate Lenses Polycarbonate Lenses are the most durable of all lenses. These lenses are over ten times more impact resistant than regular plastic. They are also one of the lightest, thinnest lens materials used in eyewear (up to 40% thinner and 30% lighter than standard plastic lenses). Polycarbonate remains a good choice if you want the safest and/or lightest lenses possible. It is also an excellent material choice for children. Hi Index Lenses Hi Index lenses are an excellent alternative for patients with higher prescriptions that want the thinnest, most attractive lenses possible. Hi Index lenses range from 20% to 65% thinner than plastic lenses (depending on the refractive index). The higher the refractive index, the thinner the lens (and typically the higher the cost). Trivex Lenses The Trivex lens is a lightweight, impact resistant material much like polycarbonate. It offers the added benefits of lower visual distortion, better optics, and inherent U.V. Protection. Trivex is a great substitute for polycarbonate lenses in prescription sunglasses because Trivex can be easily tinted, whereas polycarbonate cannot. Heritage Vision Plans 18

Glossary of Eyewear Terms Glossary of Eyewear (continued) Terms EYEGLASS LENS COATINGS AND OPTIONS There are many different choices in eyeglass lens coatings and other optical options.

20 Glossary of Eyewear Terms Glossary of Eyewear (continued) Terms EYEGLASS LENS COATINGS AND OPTIONS There are many different choices in eyeglass lens coatings and other optical options. These coatings and options can enhance the performance and appearance of eyeglass lenses. Scratch Resistant Coating The material in plastic lenses is relatively soft and is easily scratched if it is not coated with scratch-resistant coating. This coating, a much harder plastic compound, is applied to the lens surface. The " Scratch Coat " greatly increases the lens' resistance to scratches and abrasions, however it too can be scratched. Anti-Reflective or AR Coating Anti-Reflective Coatings help reduce the reflection on the lenses. When driving (day or night), or using the computer, they reduce the glare and lessen strain on the eyes. What you see is both clearer and sharper. AR Coating also cosmetically enhances the lens, making the lens almost invisible. Your eyes, not the glasses, become the focus of attention. Ultra-Violet or UV Coating UV Coating helps protect the eyes from the harmful damage caused by the sun. This protection helps the eyes tolerate bright sunlight and softens harsh light without making the glasses seem darker. (Note: Both Polycarbonate and Trivex lenses have builtin Ultra-Violet protective properties.) Photochromic or Transitions Lenses Photochromic lenses change from light to dark through changing levels of sunlight. " Transitions " is the most well-known brand in the category of Photochromic lenses. When worn indoors they are virtually clear. When worn outside they change to a dark color. Polarized Lenses Polarized Lenses block out virtually all Ultra-Violet Rays. These lenses help to eliminate haze and glare, while increasing visibility. Heritage Vision Plans 19

21 Heritage Optical Notes / Appointments

22 Member Services Center 440 E. Congress, Suite 300 Detroit, MI (Revised: 03/12/2009)

AFTER HOURS/URGENT CARE CENTERS

After Hours/Urgent Care Centers can save time by treating you quickly with no appointment. After Hours/Urgent Care Centers are available to treat minor injuries and should be used only when your PCP is