AmeriSecure: Vision Summary

Plan Provisions

Group Size:
Plan Type:
Calendar Year Deductible:
Waiting Period:
Effective Date:
Initial Rate Guarantee:

2+ Employees
PPO
None
None
1st or 15th of the month.
24 months

Underwriting/ Eligibility

Minimum Contribution:
Minimum Participation:

Administrator:
Additional Fees:
Enrollment Requirements:

Submit to Administrator:

  50% employee premium; or 25% employee & dependent premium.
  Non-contributory: 100% of all eligible employees; Contributory:
  for 2-5 employees- 100%; 6-8 employees - all but 1; 9 or more
  employees - 75% required.
  AmeriSecure Division/ Insurers Administrative Corporation (IAC).
With Dental: $0 Stand-alone: $15.00 per month.
  First month premium check payable to AmeriSecure; Group app;
  employee apps/ waivers; State Wage & Tax Summary; prior carrier
  bill/cert. if replacement.
  10 days prior to requested effective date.

Benefit Summary

	In Network	Out of Network
Comprehensive Eye Examination	$10	Up to $40 reimbursement
Exam Frequency	Annual	Annual
Eyewear Allowance	Benefit	Maximum Reimbursed
Covered, selected eyewear materials Spectacle Lenses Frames Contact lenses, in lieu of lenses & frames (includes exam, fitting 2 follow up visits and 4 boxes of disposable lenses)	$20 copay 100% 100% 100%	Single vision lenses Bifocal lenses Trifocal lenses Lenticular Frames Necessary contacts Elective contacts	$40 $60 $80 $80 $45 $210 $105
Lens Frequency Frames Frequency	Annual Plan A - every year	Annual Plan B - every two years

Other Features:
  Discount on Laser Correction - Our national vision correction partner is The Laser Center,
  which has over 50 centers nationwide.
  No ID cards needed - The provider can verify benefits by calling 800-638-3120.
  Non-network claims need to be submitted for reimbursement to:

Spectera
2811 Lord Baltimore Drive
Baltimore, MD 21244-2644

  Receipts should include your SS# and patient's date of birth. All receipts must be
  submitted together for services and materials purchased on different dates to recieve
  reimbursement.

Over 10,000 providers Nationwide - Find a provider using 800-839-3242 or
www.agac.com. Under the Employer Sponsored page, click products and
select the provider locator on the bottom of the page.

This is a brief description of coverage provided under policy form series G-19000 and is subject to the terms, limitations, and exclusions of the group policy. Please see the certificate for details.

This information is intended as a summary only; benefits may contain limitations
and exclusions. This does not replace the master policy or the plan brochure. It is as
accurate as possible, but we cannot be responsible for errors and make no warranty
of any kind.