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Value-Added Services* One-year breakage warranty included on all plan-coveredeyeglasses (i.e., all spectacle lenses, Davis Vision Exclusive Collectionframes and national retailer frames where our Exclusive Collectionis not available). Location may or may not participate in offering theExclusive Collection of frames. Please refer to an explanation of theExclusive Collection below for greater detail. Discounts on LASIK procedures. Visit qualsight.com/-state-of-tnor call (877) 515-3937 for information. Savings up to 40% off premium hearing aids through YourHearing Network. Visit davisvision.yourhearing.com or call(888) 809-0044 for more information on pricing and participatingaudiologists and otolaryngologists. Partial reimbursements are available for services provided by anout-of-network eye care professional. Claim forms are availableonline at davisvision.com/StateofTN. (You will receive the fullvalue of your benefit dollars if you select an in-network eye careprofessional.) Please note that out-of-network value-added servicesare not covered by benefit and member will be responsible for 100%of charge.Value-added services1Basic planLaser vision correction (for select eye careprofessionals)Member is responsible for85% of retail price; 95% ofpromotional priceExpanded planAdditional pair of eyeglassesMember is responsible for70% of chargeMember is responsible for60% of chargeAdditional pair of conventional or disposablecontact lensesMember is responsible for80% of chargeMember is responsible for80% of chargeMember is responsible for85% of retail price; 95%of promotional priceMember pay will not be greater than the copay, but could be less based upon the actual charge. Out-of-networkvalue-added services are not covered by benefit and member will be responsible for 100% of charge.1 *Actual costs and benefits may vary based upon plan design selected. Exclusions and limitations may apply.davisvision.com/StateofTN

Envision a World withBetter HearingHearing tests are simple, painless andwidely available. This hearing health careplan is accessible to you and your familymembers through your plan.Recognizing the signs of hearing lossThe signs of hearing loss can be vague and develop slowly,or they can be obvious and begin suddenly. Regardless,struggling to hear certain sounds or syllables is a telltalesymptom of hearing loss.QualityOur highly skillednetwork ofcredentialed hearingcare professionalsprovide you withquality care.If you recognize any signs of hearing loss in yourself ora loved one, it’s important to seek help. Get started byscheduling your free hearing exam with a Your HearingNetwork provider in your area today.Start your hearing health journey todayHearing examFREEFollow-up care1-yearTrial periodWarrantyBatteries 60-day money back guaranteeSavingsSignificant savingsincluding up to 40%off premiumhearing aids.AccessibilityYour HearingNetwork is a nationalnetwork withlicensed hearingcare providersnear you.4-year service, including 1-year of lossand damage4-year supply included with each hearingaid purchaseHearing health care services administered byReady to schedule your consultation with a local hearing care professional today?Visit davisvision.yourhearing.com or call (888) 809-0044 for moreinformation on hearing aid discounts.davisvision.com/StateofTN

Say Hello to theDavis Vision Mobile AppRegister your member account atdavisvision.com/member and thendownload the Davis Vision mobile appfor your iOS or Android device.Find an eye care professionalEasily find an eye care professional basedon your current location, or search by city,ZIP code or name.Check your eligibility and benefitsQuickly check your current or future eligibilitystatus. Need a little more detail? You can alsoreview your benefit.Request an ID cardNeed your member information?Find it and personalize it with yourphoto (optional).Need more information?Go to davisvision.com/appto learn more and see the appin action.Review your claims and statusCheck out your current claims and history.Plus, upload a photo of your receipt toeasily submit an out-of-network claim.Other tools and resourcesBe sight-savvy with calculators, a frametry-on tool, a vision reference libraryand more.davisvision.com/StateofTN

The Exclusive Collection of FramesMembers are offered a selection of over 200 fashionable frames for little-to-no out-of-pocket cost. You’llfind the Exclusive Collection at participating in-network eye care professional locations.Our convenient tagging system is designed to streamline understanding of your member out-of-pocketcost. Actual costs and benefits may vary based upon plan design selected. Exclusions and limitationsmay apply.Fashion/yellow tag— Functional and classic with designsfor the whole familyBasic plan: 0 copay I Expanded plan: 0 copayDesigner/red tag— Stylish options with brands like Robert Mitchel ,Lucky Brand , Jones NY and moreBasic plan: 15 copay I Expanded plan: 0 copayPremier/blue tag— Fashion-forward choices from brands likePerry Ellis , Catherine Deneuve and Candies Basic plan: 40 copay I Expanded plan: 0 copayYou’ll find the Davis Vision Exclusive Collection atparticipating in-networkeye care professionallocationsdavisvision.com/StateofTN

Frequently Asked QuestionsHow do I enroll?To enroll, sign up within 30 calendar days from yourdate of hire. If you do not enroll when initially eligible,you must wait until the next annual enrollmentperiod to enroll, unless you experience a specialqualifying event.For more details about the plan, log on todavisvision.com/StateofTN or call (800) 208-6404.Is my family covered?Once enrolled, log in to your member account andclick on “Check Eligibility” to see who is covered. Youcan add (or drop) dependents to your plan during theannual enrollment period or in the case of a specialqualifying event.When does my coverage end?Please refer to the “Termination of Insurance” and“Continuation” sections in either your Basic orExpanded sample certificate to verify the date yourcoverage will end upon terminating your benefit orleaving employment. You may also ask your ABC, HRrepresentative or employer to assist you inthis matter.What information will my eye doctor need?When scheduling your appointment with an innetwork eye care professional, it’s best to have yourmember number so they can quickly verify eligibility.However, you can also use the head of contract’sfirst and last name and the state in which they live.Where do I find my member number?Your member number can be found on your DavisVision Member ID card, by logging in to yourDavis Vision account, or by calling us at(800) 208-6404.Do I get a member ID card? What happens if Ilose it?Yes, the head of contract will receive a MemberID Card; covered dependents do not. However,you do not need the ID card to use your benefits.Replacement cards can be ordered through youronline account or by calling (800) 208-6404.What are your hours of operation?Our customer care center is open seven daysa week at convenient times for all areas of thecountry and can be reached at (800) 208-6404.The operating hours are:M–FET8 a.m.–11 p.m.M–FCT7 a.m.–10 p.m.Sun.12 p.m.–4 p.m.Sun.11 a.m.–3 p.m.Sat.9 a.m.–4 p.m.Sat.8 a.m.–3 p.m.Participation requirements means an agency must be participating in the State of Tennessee Sponsored Group Health Plan in order to qualify forparticipation in the State of Tennessee Voluntary Group Vision Insurance Program. An active Employee and/or Dependent’s participation in the StateSponsored Group Health Plan is not required to participate in the State Group Vision Insurance Program. A Retiree and/or Dependent’s participationin the State Sponsored Group Health Plan is required to participate in the State Group Vision Insurance Program. Employee or Retiree’s participationin the State Group Vision Insurance Program is required for participation of eligible Dependents, except Dependents of Retirees may continueenrollment in the State Group Vision Insurance Program after the Retiree is no longer eligible for the State Group Health Insurance Plan and StateGroup Vision Insurance Program due to reaching the age for Medicare as long as the Dependents remain enrolled in the State Group Health InsurancePlan. Participation by those enrolled in the State Group Vision Insurance Program is on a calendar year basis, and enrollment may only be dropped bythe participants during the Annual Enrollment Period for the beginning of the next calendar year or due to a special qualifying event.davisvision.com/StateofTN

What if my eye care professional is notin-network?The Basic Plan offers limited out-of-networkbenefit options, while the Expanded Plan offersmore reimbursement options. (See plans on pages5 and 6 for more details.) To submit an out-ofnetwork claim, visit davisvision.com/StateofTNand click on “Access Benefits and Forms” todownload the Direct Reimbursement Claim form.Follow the instructions on the form to submityour claim. You must include either your eye careprofessional’s signature or a detailed receipt. Youcan request to add an eye care professional toyour network under “Find an eye care professional”at davisvision.com/StateofTN.!Tip: Download the the DirectReimbursement Claim form from themember portal and bring it with you toyour appointment for easy completionof the eye care professional informationand for their signature.What is included in an eye examination?An eye exam takes roughly an hour and consistsof a variety of checkups, which include a healthreview, simple visual acuity tests, refractiontest, visual field test, glaucoma test, slitlampevaluation and dilation. A comprehensive eyehealth exam can detect a number of eye diseases,as well as signs of systemic conditions such asdiabetes, thyroid disease, high blood pressure andneurological impairments. Every eye exam our eyecare professionals administer is consistent withclinical guidelines published by the Eye AmericanOptometric Association and the AmericanAcademy of Ophthalmology.What is a dilated retinal exam?A Dilated Retinal Examination is a criticaldiagnostic procedure in the detectionand management of diabetes, glaucoma,hypertension and many other ocular and/orsystemic diseases (up to 30 altogether). It canlead to higher quality patient care, improvedlifestyle through early detection and intervention,and possibly lower your overall health care costs.Do I have to get all the services completed atthe same time?As a Davis Vision member, you can get an eyeexam and shop for eyewear at different times andin different locations. For example, you may getyour eye exam from an eye care professional andthen use your prescription to shop for glasses atan in-network retailer at a later date within thesame plan year.Does my whole family have to visit thesame eye care professional?No. Plan dependents can visit different eye careprofessionals. For example, students who areaway at school can locate a participating eye careprofessional near them.Can I get both glasses and contact lenses?No. Your plan benefits will cover eyeglasses orcontact lenses, but not both. We are, however,able to offer our members additional discountson certain eyewear and eye care purchases evenafter the plan allowances have been used. Login to your account to view plan details, or call usat (800) 208-6404.What if my glasses break?All eyeglasses come with a one-year breakagewarranty for repair or replacement of the frameand/or lenses, which applies to all plan-coveredeyeglasses (i.e., all spectacle lenses, Davis VisionExclusive Collection frames and national retailerframes where our Exclusive Collection is notavailable). So if your glasses break, simply returnthem to where you purchased them.Can I use my insurance when shopping online?Your Davis Vision benefits are available for innetwork use online at visionworks.com. Onlinepurchases for glasses or contacts at other sitesare currently considered out-of-network. Yourbenefits will work the same at visionworks.com asthey would in-store at a Visionworks location.davisvision.com/StateofTN

Buy Eyewear OnlineWith Your Benefits1-800 Contacts is one of the most recognized online contact lens retailersin the industry. They have an established reputation for their customerservice, backed by an industry-leading Net PromoterScoreof 76. Learn more: 1800contacts.comBefitting has artificial intelligence-driven tools to find the perfect pair of eyeglasseswith personalized, curated recommendations. Shop for single and progressivelenses, prescription sunglasses and advanced blue light blocking lenses. Freeshipping and returns are also included. Learn more: befitting.comGlasses.com is one of the most trusted online stores for popular eyewearbrands, including prescription glasses and sunglasses. Learn more: glasses.comLook up your benefits and see the savings on thousands of differentframes and contact lenses as you shop. Learn more: visionworks.comWhat kind of brands do the online retailers carry?All of the online retailers feature top brands of bothframes and contacts.Do I need a prescription to order products online?Yes; you will need a recent valid prescription topurchase contact lenses online, and you will need toenter your prescription at the time of purchase.Are the benefits the same as other retail stores?Yes; you can use your full benefit.Is the Davis Vision Exclusive Collection included?No; the Exclusive Collection is not offered atthis time.davisvision.com/StateofTN

Basic Plan Premium Rates*Employee/retiree ratesMonthlyAnnuallyEmployee 3.07 36.84Employee child(ren) 6.13 73.56Employee spouse 5.82 69.84Employee family 9.01 108.12Expanded Plan Premium Rates**Employee/retiree ratesMonthlyAnnuallyEmployee 5.56 66.72Employee child(ren) 11.12 133.44Employee spouse 10.57 126.84Employee family 16.35 196.20Need further assistance?Give us a call:(800) 208-6404Actual costs and benefits may vary based upon plan design selected. Exclusions and limitations may apply.Eligibility for vision benefits may be affected by certain life events. Life event means one of the following: (1) your marriage or divorce; (2) the death of your spouse;(3) the birth or adoption of your Child; (4) the death of your Child; (5) a change in the employment status of your spouse; or (6) a change in your employment statusor a qualifying event as defined by the State of Tennessee.The Schedule of Benefits in this document reflects, unless otherwise approved by the State, the procedures that vision will cover as well as certain limitations andexclusions for these covered benefits. These services will be covered when a vision eye care professional provides them. These services must be necessary andmust be provided in accordance with generally accepted vision practice standards. If the total benefit charge for a Member is less than the benefit cost-sharing,the Member shall pay the lesser charge. In addition to the limitations and exclusions shown in the Schedule of Benefits section, the Vision Plan does not pay for thefollowing unless otherwise approved by the State:General Limitations & ExclusionsA. Treatment of injury or illness covered by Workers’ Compensation or Employer’s Liability Laws.B. Services received without cost from any federal, state or local agency. This exclusion will not apply if prohibited by law.C. Cosmetic surgery or procedures for purely cosmetic reasons.D. Charges by any hospital or other surgical or treatment facility and any additional fees charged by the vision for treatment in any such facility.E. Services by an eye care professional beyond the scope of his or her license.F. Vision services for which the patient incurs no charge.G. Vision services where charges for such services exceed the charge that would have been made and actually collected if no coverage existed.H. Orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses.I. Any eye or Vision Examination, or any corrective eyewear required by a Policyholder as a condition of employment; Safety eyewear.J. Lost or broken lenses, frames, glasses, or contact lenses will not be replaced except in the next Benefit Frequency when Vision Materials would nextbecome available.Optional Materials & ServicesIf the materials and services rendered exceed the covered benefit, the difference for the actual materials or services rendered is due from the member.We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex.Davis Vision coverage is underwritten by HM Life Insurance Company, Pittsburgh, PA, under policy form series HMP 902-VIS or similar. The coverage or servicerequested may not be available in all states and is subject to individual state approval.from(800) fTN

Aug 11, 2021 · Extensive blended network of premier retailers nationally as well as independent optometrists and ophthalmologists, totaling over 104,0003 points of access NCQA-certified eye care professional credentialing process to ensure industry-leading standards for q