Law Enforcement Health Benefits 2233 Spring Garden Street, Philadelphia, PA 19130, 215-763-8290 http://www.lehb.org

Members will continue to be COVERED as long as they are in ACTIVE STATUS. BENEFITS will TERMINATE due to a Resignation, Dismissal, or ALL Leave of Absences, except for Family Medical Leave of Absence & Military Leave of Absence (Post 911) War on Terrorism.

RETIRED Police Officers and Unmarried Eligible Dependents are COVERED for FIVE (5) YEARS plus any additional years converted from sick time.

UNMARRIED DEPENDENTS ELIGIBLE FOR ENROLLMENT
Your legal spouse and all unmarried, biological or adopted children under 19 years of age are eligible for enrollment.  Children are eligible from birth with a copy of the birth certificate listing the covered member’s first and last name, or adoption papers.  An unmarried dependent child is covered until the end of the month in which he/she turns 19 years of age.  Unmarried dependent children in full-time attendance at an accredited secondary school or college may be included up to age 23 upon receipt each semester (twice a year), of our required student verification form (available on L.E.H.B. website http://www.lehb.org). Benefits will terminate the last day of the month of graduation regardless of age.

An unmarried child, who is physically or mentally incapable of self-support prior to attaining age 19, may be continued under the plan while remaining incapacitated and unmarried, subject to your own coverage continuing in effect.  A letter of verification (Independence Blue Cross disability form) is required on an annual basis from the unmarried dependent’s physician.

VISION BENEFITS
The L.E.H.B. Vision Fund helps promote good eyesight for you and your family.  It also aims to minimize the development of more severe vision problems, which could lead to blindness and/or other long-term deficiencies.  The L.E.H.B. Vision Fund strongly urges you and your family to maintain routine vision check-ups.

• Members will receive an explanation of benefits form (EOB) which will indicate when patient is eligible for next routine eye exam.
• If member is unclear if eligible for routine eye exam please call (215) 364-3529
• Confirmation number is not required to process and pay claims

Member should only use vision providers who post frame cost on frames.

FREE CHOICE OF VISION CARE PROVIDERS
By selecting a L.E.H.B. participating vision provider you minimize your out of pocket expense and are guaranteed to receive the highest level of care by maximizing the vision benefits.

We have an available list of 356 participating vision providers either on the web (http://www.lehb.org) or you may call for a booklet.  The participating providers have agreed to accept the L.E.H.B. vision payment as payment in full for a complete eye examination and a pair of basic eyeglasses.  Extra charges may apply if designer frames, contact lenses, and/or special spectacle lens options are selected.

Out of Network Vision Providers will be reimbursed 75% of allowed rate.

FREQUENCY OF BENEFITS
All eligible employees, spouses’ and unmarried eligible dependent children are eligible for the following vision benefits:

• Vision Exam.
  • Optometrist $33.00
  • Ophthalmologist $40.00
  • Once every 12 months
  • Each exam shall consist of but not be limited to:
    

    1.	A complete history of patient.	5.	Tonometry
    2.	External examination of the eyes and adnexa, papillary reflexes, cover test ocular motilities, convergence near point.	6.	Refraction
    3.	Ophthalmoscopy	7.	Stereopsis testing
    4.	Biomicroscopy	8.	Color vision testing

VISION FEE SCHEDULE----SERVICE MAXIMUM ALLOWANCE
Frames—once every 12 months

• Wholesale cost  $30.00
  Network providers must make 100 frames available to members at no cost ($30.00 wholesale allowance)

Lenses—once every 12 months

• Single vision $32.00
• Bifocal $50.00
• Trifocal $60.00*
• Progressive $80.00*
• Lenticular $100.00 (with prior approval)
  *submitted with lab bill

Contacts—once every 12 months in lieu of frames and lenses

• L.E.H.B. will reimburse provider
  • Contact lenses $80.00
  • Therapeutic Contacts $175.00 (with prior approval)

Participating providers agree to charge a maximum of no more than $50.00 for standard 2-week disposable soft contact lenses; i.e. the eligible member or dependent should not be charged more than $50.00 towards his contact lens and exam fee total fee.

• $33.00 Exam fee paid for by L.E.H.B.
• $80.00 Contact lens fee paid for by L.E.H.B.
• $50.00 From member
• $163.00 Global contact lens fee
  The global contact lens fee (eye examination, contact lens fitting, 4 boxes of contact lenses, care kit, and 6 months follow-up care) should not exceed $163.00 for a standard 2-week modality soft contact lens. The 2-week modality includes but is not limited to:

• Acuvue	Soflens 59	Fresh Look
  Softlens 38	Biomedics 55	Vertex
  Focus 1-2 week	Biomedics 38
  Acuvue 2	Choice AB

Lens Options

• Polycarbonates $10.00 paid by L.E.H.B.

VISION PLAN EXCLUSIONS
NO PORTION of the materials of related fees will be paid under this plan for the following:

• Field Vision Test
• Medical or Surgical treatment for the eyes
• Repair Charges
• Retinal Photography
• Replacement of scratched, lost or broken lenses or frames
• Sunglasses

The following lenses or lens options are not covered under your vision plan.  You are urged to discuss the costs of these items prior to making your selection, since you are responsible for full payment directly to the provider.

IMPORTANT NOTE:

• Glasses and/or contact lenses will not be funded unless the prescription is a .50 DIOPTER OR GREATER in any one field, sphere, cylinder or both.