NNEBT

VISION BENEFIT

Your health Plan includes a vision benefit. The vision benefit program is administered by Davis Vision. The vision program has both in-network and out-of-network benefits.

Benefits

Benefits will be available for you and your spouse once every 24 months and once every 12 months for your dependent children up to the age of 19.

In-Network

The following services and products are available at no cost if accessed in-network:

I. Vision analysis, including

• Case history
• Examination for pathology or anomalies
• Refraction
• Coordination tests and measurement
• Tonometry for adults or dependents where indicated
• Near point analysis
• Prescription, if needed
• Dilation, as professionally indicated

II. Lenses and frames, including

• Prescribing and ordering tests
• Assisting with frame selection
• Verifying finished glass/lens accuracy
• Proper fitting and adjustment of glasses
• Follow up frame adjustments

III. Contact lenses

• Soft, standard, daily-wear soft contact lenses only
• Care kit for proper sterilization
• Necessary visits for proper fitting

In lieu of eyeglasses, you may select two multi-packs of disposable contact lenses (6 lenses each) with a $20.00 co-payment (applies to member, spouse and dependents). Whether you choose eyeglasses or contact lenses, you may receive a separate pair of glasses, single vision lenses only, for a co-payment of $25.00 (this benefit is restricted to the member and spouse). The following optional items also are available as part of your in-network benefit:

In-Network (Cont’d)

In-network services are available only through participating providers. In-network frames are from the “Tower Collection.” If you use an in-network provider but choose a frame other than from the “Tower Collection,” you will receive a $25.00 allowance toward the purchase of the frame and you will be responsible for the balance of the cost of the frame. If you require or select contact lenses other than those available through Davis Vision, you will receive a $105.00 allowance toward the purchase of the contact lenses and you will be responsible for the balance of the cost of the contact lenses.

A one-year unconditional breakage warranty is provided for all eyeglasses, obtained in-network and supplied by Davis Vision.

Out-Of -Network

If you receive services from a non-panel provider, you are required to pay the provider directly. You will be reimbursed up to $45.00 for the eye examination and $55.00 for eyeglasses or contacts.

NOTE: Under either the in-network or out-of-network benefit, you must claim all parts of the benefit (exam, lenses and frames) at one time and through a single provider.

How To Receive The Benefit

In-Network

Contact Davis Vision to find a participating provider in your area. You can call Davis Vision, toll free, at 1-800-999-5431 between 8:00 a.m. and 8:00 p.m., Monday through Friday, and between 9:00 a.m. and 4:00 p.m. on Saturday or you can contact Davis Vision at http://www.davisvision.com. Once you have identified a participating provider who you wish to use, you call the provider directly to make an appointment, informing the provider, during that call, that you have Davis Vision through Northern New England Benefit Trust. The provider will contact Davis Vision to confirm your eligibility and receive an authorization number.

Out-Of-Network

You must call Davis Vision and obtain a claim form. Complete the form as indicated, attach an itemized bill and mail the form to the address listed on the form.

Special Feature

Free membership in and access to Lens 1-2-3, a mail order replacement contact lens service providing a fast and convenient way to purchase replacement contact lenses at significant savings, is available to you. For more information, please call 1-800-LENS-123 (1-800-536-7123).

Revised: September 2002