VISION

Filing a Claim

When you receive out-of-network care, you must pay your provider in full for all services and materials. You then complete and submit an Out-Of-Network Claim Form. Please follow the instructions provided on the form and include your itemized receipt to EyeMed that shows the cost or charges for the eye examination, lens type and frame. You should be sure to include your name, mailing address, EyeMed member identification number and the Valassis group number. If the services are for a covered family member, you should also include the patient's name, relationship to you and date of birth.

If your provider is not currently an EyeMed provider, you can nominate him/her to EyeMed. Please complete a Nomination Form and forward it to the e-address or fax number on the form.

Claims for out-of-network reimbursement must be provided to EyeMed within 12 months of the date of service:

EyeMed Vision Care
Attn: Out-of-Network Claims
P.O. Box 8504
Mason, OH 45040-7111

Fax completed form and supporting documentation to: 866-293-7373 or email to oonclaims@eyemedvisioncare.com

www.eyemedvisioncare.com

	Highlights Eligibility, Enrollment & Cost How the Plan Works Covered Expenses & Services Expenses Not Covered Filing a Claim Numbers, Addresses & Links

Summary Plan Description
The legal summary of this benefit will be included in the 2008 Benefits Handbook.