COMPREHENSIVE BENEFITS AND CLAIMS ADMINISTRATION

August 8, 2005   HFCC-FT, AFT 1650 VISION CARE BENEFITS Eye exam 100% (Limited to one exam, per person, in a 12 month period) Lenses and Frames 90% of charge (Limited to one set of lenses and frames in a 12 month period) Contact Lenses 90% of charge (Limited to one set in a 12 month period. However, disposable contacts will be limited to a 12 month supply) Maximum Benefit for Vision Care $400 per 12 month period Note: Benefits are limited to one pair of eyeglasses OR the contact lenses benefit above, but not both. Vision care benefits apply when vision care charges are incurred by a Covered Person for services that are recommended and approved by a Physician or Optometrist. BENEFIT PAYMENT Benefit payment for a Covered Person will be made as described in the Schedule of Benefits. VISION CARE CHARGES Vision care charges are the Usual and Reasonable Charges for the vision care services and supplies shown in the Schedule of Benefits. Benefits for these charges are payable up to the maximum benefit amounts shown in the Schedule of Benefits for each vision care service or supply. Covered Charges include: (1) Examinations by licensed Ophthalmologists or Optometrists; (2) Prescription lenses (including contacts, oversized, tinted and varilux lenses); (3) Frames with the purchase of prescription lenses. LIMITS No benefits will be payable for the following: (1) Before covered. Care, treatment or supplies for which a charge was incurred before a person was covered under this Plan. (2) Excluded. Charges excluded under Plan Exclusions. (3) Health plan. Any charges that are covered under a health plan that reimburses a greater amount than this Plan. (4) No prescription. Charges for lenses ordered without a prescription. (5) Orthoptics. Charges for orthoptics (eye muscle exercises). (6) Repair/replacement. Charges for repair or replacement of broken or lost lenses or frames. (7) Sunglasses. Charges for safety goggles or sunglasses, that are not covered by a prescription. (8) Surgery. Charges for vision surgery (i.e. Radial Keratotomy). (9) Training. Charges for vision training or subnormal vision aids. Third Party Administrator: CBCA, Inc. P.O. Box 902 Beattyville, KY 41311 Phone: (800) 832-3709 FAX: (952) 946-7547 EMPLOYEES CAN CALL CBCA AT 800-832-3709 To verify eligibility and benefits call: CBCA at 800-832-3709 BILLING INSTRUCTIONS
NO CLAIM FORMS ARE REQUIRED, however, in order for bills to be processed without delay, the following information must be provided on the statement.
1. Name of Employer -Henry Ford Community College	6. Provider's Name and Tax       I.D.
2. Group Number -100750	7. Date of Service
3. Name of Employee	8. Description and Diagnosis
4. Name of Patient	9. If accidental injury, describe       how, when and where the       accident happened.
5. Employee Number -Social Security Number	10. Other coverage information
SEND CLAIMS TO: CBCA Administrators PO Box 902 Beattyville, KY 41311 FAX Number: 952-946-7547 E-Mail: GR-customer service@cisgi.com Website: CBCA Quick Login