New Employee Benefits Enrollment - Dow Corning

VISION
Out-of-Network Benefits
If you choose to receive services from a provider who is not in the network, you will need to pay upfront
and then be reimbursed up to the amounts listed below. You will also need to send your itemized
receipts, with the primary-insured’s unique identification number and the patient’s name and date of
birth, to:
Spectera Claims Department
P.O. Box 30978
Salt Lake City, UT 84130
Fax number: (248) 733-6060
Exam Lenses Frames Contact Lenses
Optometrist, $40
Ophthalmologist, $40
You should know…
Single vision, $40
Bifocal, $60
Trifocal, $80
Lenticular, $125
$45 Elective, $150
Necessary, $210
� Some of the Spectera network providers offer only eye exams at the network level, and do not
offer materials at the program rate. In this case, your eye exam would be covered in full (after
your $15 co-pay), and frames, lenses or contacts would be covered as an out-of-network
benefit. The Future Member feature on the Spectera web site will indicate the provider’s level
of participation (exam only, or exam plus materials).
� Some retail providers, such as Wal-Mart and D.O.C., are included in the Spectera network. For
a listing of providers, go to www.spectera.com and click on the Future Member feature.
� Refractive laser eye surgery – As a Spectera member, you can receive 5%-15% off refractive
eye surgery with contracted providers throughout the United States. For details and a list of
providers visit www.spectera.com.
Annual Employee Contribution for 2008
Employee Only Employee + One* Employee + Two or More*
Vision Plan $ 96 $ 192 $ 288
Waiver $ 0 $ 0 $ 0
* Per IRS regulations, Dow Corning cannot withhold benefit premiums for a domestic partner on a pre-tax basis.
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