SUMMARY OF BENEFITS SCHEDULE

Disclaimer: Your eligibility for your benefits is determined by your collective bargaining agreement. Eligibility is determined for all services. If you have any questions as to the appropriate application that you should submit, please contact the Fund office.

The plan will provide the following optical benefits when performed by a participating eye doctor. Please refer to the Participating Provider Directory which will be sent to you when you request a claim form.

- a complete eye examination by a participating eye doctor one a year*, and
- lenses once a year*, and
- frames once every two years* (however, if the frames are broken they will be replaced after at least one year* has elapsed provided contact lenses were not obtained the previous year).
- contact lenses - one allowance is made toward contact lens fitting/contact lenses. This allowance is in lieu of all other vision benefits.

* A YEAR IS DETERMINED AS 12 MONTHS FROM THE DATE THE LAST CLAIM FORM WAS ISSUED .

Note: Charges for Vision Services or material not covered, or limited under the service contract must be paid to the Doctor by the patient or member before materials are delivered.

Please do not make an appointment with the Doctor until you have received the Claim Form.

IMPORTANT
You will be given a list of participating doctors who have agreed to furnish complete vision care services.
Payment will be made only to the participating doctors in accordance with the service contract.