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1 DeltaVision Individual Vision Plan Options -- Advantage Network, Fixed Fee Vision Care Services Member Cost In-Network Out-of- Network Allowance Exam with Dilation as Necessary: $30 Frames: $0 Copay; $120 allowance, Any frame available at provider location 20% off balance over $120 $60 Standard Plastic Lenses: Single Vision Bifocal Trifocal Standard Progressive* Premium Progressive* $70 Copay $70 Copay, 80 % of Charge, less $110 Allowance $25 $55 Lens Options: Standard Plastic Scratch Coating $0 $5 Contact Lenses: (Discount applies to materials only) Conventional Disposable Medically Necessary Frequency: Examination, Frame, Lenses or Contact Lenses Monthly Premium Rates $0 Copay; $80 allowance, 15% off balance over $80 $0 Copay; $80 allowance, plus balance over $80 $0 Copay, Paid-in-Full Once every 12 months $64 $64 $200 Individual: $4.57 Individual + Family: $12.57 * Standard/Premium Progressive lenses not covered - fund as a Bifocal Lens. Please see Benefit Summary for limitations. In-Network Additional Discounts: Member Discount Exam Options: Standard Contact Lens Fit and Follow-Up: Up to: Premium Contact Lens Fit and Follow-Up: 10% off Retail Lens Options: UV Treatment $12 Tint (Solid and Gradient) $12 Standard Polycarbonate $35 Standard Anti-Reflective Coating Other Add-Ons and Services 30% off Retail Price Member receives a 30% discount on items not covered by the plan at network Providers, which cannot be combined with any other discounts or promotional offers. Discount does not apply to EyeMed provider's professional services, or contact lenses. Members also receive 15% off retail price or 5% off promotional price for Lasik or PRK from the US Laser Network, owned and operated by LCA Vision. Members also receive a 40% discount off complete pair eyeglass purchases and a 15% discount off conventional contact lenses once the funded benefit has been used. NOTE: If you enroll by the 10th of the month, coverage will begin the 1st day of the following month. DeltaVision is offered through Canyon Insurance Services, Inc., a wholly owned subsidiary of Delta Dental of, in partnership with EyeMed Vision Care, LLC.
2 AZ CITY OF SIERRA VISTA DAYNES OPTICAL INC 400 W FRY BLVD STE 9 (520) SIERRA VISTA, AZ EL MERCADO LOOP (520) SIERRA VISTA, AZ COLONIA D SALUD STE A 100 (520) SIERRA VISTA, AZ CITY OF WILLCOX Cochise County 780 REX ALLEN DR (520) WILLCOX, AZ Coconino County CITY OF FLAGSTAFF BARNET DULANEY PERKINS EYE CTR1030 N SAN FRANCISCO BLVD STE 130 (602) FLAGSTAFF, AZ N HWY 89 (928) FLAGSTAFF, AZ N HWY 89 (928) FLAGSTAFF, AZ GENA OPTICAL 1900 W CHANDLER BLVD STE 13 (480) CHANDLER, AZ W CHANDLER BLVD STE 2104 (480) CHANDLER, AZ CHANDLER VILLAGE DR (480) CHANDLER, AZ CITY OF GILBERT ASSOCIATED OPHTHALMOLOGISTS 4915 E BASELINE RD SUITE 114 (480) GILBERT, AZ E WILLIAMS FIELD RD STE 124 (480) GILBERT, AZ PER SPECTACLES 1040 S GILBERT RD STE 101A (480) GILBERT, AZ S GILBERT RD (480) GILBERT, AZ CITY OF GLENDALE ASSOCIATED OPHTHALMOLOGISTS 5620 W THUNDERBIRD RD STE H-3 (602) GLENDALE, AZ W ARROWHEAD TOWNE CENTER (623) GLENDALE, AZ Gila County CITY OF MIAMI BARNET DULANEY PERKINS EYE CTR2250 E HWY 60 STE D (602) MIAMI, AZ Graham County CITY OF SAFFORD BARNET DULANEY PERKINS EYE CTR825 20TH AVE (928) SAFFORD, AZ W 16TH ST (928) SAFFORD, AZ Greenlee County CITY OF CLIFTON BARNET DULANEY PERKINS EYE CTR US HWY 191 (928) CLIFTON, AZ CITY OF ANTHEM ARIZONA EYE CARE Maricopa County 3655 W ANTHEM WY STE B149 (623) ANTHEM, AZ CITY OF CHANDLER CRYSTAL COVE EYE CONSULTANTS700 N 54TH ST (480) CHANDLER, AZ W ARROWHEAD (623) GLENDALE, AZ ARROWHEAD TOWN CTR (623) GLENDALE, AZ W NORTHERN AVE (623) GLENDALE, AZ CITY OF GOODYEAR 1515 N LITCHFIELD (623) GOODYEAR, AZ S COTTON LN (623) GOODYEAR, AZ CITY OF MESA BARNET DULANEY PERKINS EYE 1837 W GUADALUPE RD STE 118 (602) MESA, AZ BARNET DULANEY PERKINS EYE CEN6335 E MAIN ST (602) MESA, AZ ELITE OPTICAL LLC 1635 GREENFIELD RD (480) MESA, AZ HEATHER R BETSKO 777 W SOUTHERN AVE STE 515 (480) MESA, AZ Visit for current provider information. Page 1
3 6525 E SOUTHERN AVE (480) MESA, AZ E CACTUS RD STE 240 (602) PHOENIX, AZ W SOUTHERN AVE STE 2242 (480) MESA, AZ E HIGH ST SPACE 111 (480) PHOENIX, AZ E SOUTHERN AVE STE 1508 (480) MESA, AZ METRO PKWY W STE 1000 (602) PHOENIX, AZ W SOUTHERN AVE (480) MESA, AZ LIFETIME EYE CARE 3961 E CHANDLER BLVD STE 106 (480) PHOENIX, AZ W SOUTHERN AVENUE (480) MESA, AZ OPTOMETRIC SPECIAL TESTING CTR12450 N 32ND ST STE 2 (602) PHOENIX, AZ E SOUTHERN AVE (480) MESA, AZ N TATUM BLVD STE (480) PHOENIX, AZ S STAPLEY DR (480) MESA, AZ PRIMARY EYE CARE CENTER OF AHW16515 S 40TH ST STE 111 (480) PHOENIX, AZ FALCON DR (480) MESA, AZ N METRO PKWY W (602) PHOENIX, AZ NORTH POWER ROAD (480) MESA, AZ EAST THOMAS ROAD (602) PHOENIX, AZ S POWER RD (480) MESA, AZ CACTUS RD (602) PHOENIX, AZ CITY OF PEORIA N LAKE PLEASANT PKWY (623) PEORIA, AZ W BELL RD (623) PEORIA, AZ CITY OF PHOENIX ACCENT EYE CARE NORTH 35TH AVENUE (602) PHOENIX, AZ ASSOCIATED OPHTHALMOLOGISTS 300 E OSBORN RD (602) PHOENIX, AZ BARNET DULANEY PERKINS EYE CEN4800 N 22ND STREET (602) PHOENIX, AZ E CACTUS RD (602) PHOENIX, AZ E CAMELBACK RD STE B2 (602) PHOENIX, AZ N 75TH AVE STE 101 (623) PHOENIX, AZ E CACTUS (602) PHOENIX, AZ W THOMAS RD (623) PHOENIX, AZ E BELL RD STE B-12 (602) PHOENIX, AZ W CAMPBELL AVE STE 102 (623) PHOENIX, AZ N SEVENTH ST (602) PHOENIX, AZ N TATUM BLVD (480) PHOENIX, AZ N 19TH AVE (602) PHOENIX, AZ WARREN H HELLER MD 515 W BUCKEYE RD STE 104 (602) PHOENIX, AZ CITY OF QUEEN CREEK S ELLSWORTH LOOP RD (480) QUEEN CREEK, AZ CITY OF SCOTTSDALE ASSOCIATED OPHTHALMOLOGISTS 7245 E OSBORN STE 4 (480) SCOTTSDALE, AZ Visit for current provider information. Page 2
4 7014 CAMELBACK RD STE 2140 (480) SCOTTSDALE, AZ E CAMELBACK RD (480) SCOTTSDALE, AZ Navajo County CITY OF LAKESIDE 5658 HWY 260 STE 260 (928) LAKESIDE, AZ N PIMA RD STE 104 (480) SCOTTSDALE, AZ NORTH CIVIC CTR PLAZA (480) SCOTTSDALE, AZ N SCOTTSDALE (480) SCOTTSDALE, AZ CITY OF SUN CITY BARNET DULANEY PERKINS EYE CEN9425 W BELL RD (602) SUN CITY, AZ W THUNDERBIRD BLDG A-100 (623) SUN CITY, AZ CITY OF SURPRISE BARNET DULANEY PERKINS EYE CTR14239 W BELL RD STE 216 (602) SURPRISE, AZ W BELL RD (623) SURPRISE, AZ CITY OF TEMPE 5000 ARIZONA MILLS CIR STE 165 (480) TEMPE, AZ S RURAL RD STE 115 (480) TEMPE, AZ CITY OF SHOW LOW BARNET DULANEY PERKINS EYE CTR1500 S WHITE MOUNTAIN RD STE 120 (602) SHOW LOW, AZ E SHOWLOW LAKE RD (928) SHOW LOW, AZ Pima County CITY OF GREEN VALLEY BARNET DULANEY PERKINS EYE CTR1131 S LA CANADA STE 201 (520) GREEN VALLEY, AZ VISTA EYE CARE PLC 516 E WHITEHOUSE CANYON RD STE 160 (520) GREEN VALLEY, AZ CITY OF ORO VALLEY BARNET DULANEY PERKINS EYE CTR1171 E RANCHO VISTOSO BLVD STE 125 (520) TUCSON, AZ CITY OF TUCSON BARNET DULANEY PERKINS EYE CTR698 E WETMORE STE 100 (520) TUCSON, AZ E BROADWAY (520) TUCSON, AZ N ORACLE RD (520) TUCSON, AZ Mohave County CITY OF BULLHEAD CITY RIVERVIEW VISION CENTER 3640 HWY 95 STE 100 (928) BULLHEAD CITY, AZ CITY OF KINGMAN RIVER VIEW VISION CENTER 2215 HUALAPI MTN RD (928) KINGMAN, AZ CITY OF LAKE HAVASU CITY 5651 HWY 95 NORTH (928) LAKE HAVASU CITY, AZ RIVER VIEW VISION CENTER 14 SCOTT DR (928) LAKE HAVASU CITY, AZ INJO STE 102 (928) LAKE HAVASU CITY, AZ S LAKE HAVASU AVE (928) LAKE HAVASU CITY, AZ N ORACLE RD STE 808 (520) TUCSON, AZ N ORACLE RD (520) TUCSON, AZ E BROADWAY BLVD STE 302 (520) TUCSON, AZ E BROADWAY BLVD (520) TUCSON, AZ N ORACLE RD (520) TUCSON, AZ PETER LANGENFELD 5405 E GRANITE BLDG 2527 (520) TUCSON, AZ N ORACLE RD (520) TUCSON, AZ E BROADWAY (520) TUCSON, AZ Visit for current provider information. Page 3
5 1225 W IRVINGTON ROAD (520) TUCSON, AZ N ORACLE RD (520) TUCSON, AZ Pinal County CITY OF APACHE JUNCTION 110 S IDAHO RD (480) APACHE JUNCTION, AZ CITY OF CASA GRANDE 560 N CAMINO MERCADO STE 1 (520) CASA GRANDE, AZ THE VISION CENTER IN WAL-MART 1741 E FLORENCE BLVD (520) CASA GRANDE, AZ CITY OF COOLIDGE 371 W CENTRAL (520) COOLIDGE, AZ CITY OF FLORENCE THE FOCAL POINT VISION CENTER 360 N MAIN ST (520) FLORENCE, AZ Santa Cruz County CITY OF NOGALES 1815 N MASTICK WAY (520) NOGALES, AZ Yavapai County CITY OF COTTONWOOD 270 S CANDY LANE (928) COTTONWOOD, AZ CITY OF PRESCOTT 3250 GATEWAY BLVD STE 152 (928) PRESCOTT, AZ GATEWAY BLVD (928) PRESCOTT, AZ WILLOW CREEK RD. (928) PRESCOTT, AZ CITY OF SEDONA SEDONA EYE CARE 95 SOLDIERS PASS RD STE A1 (928) SEDONA, AZ VALLEY VERDE SCHOOL RD STE 105 (928) SEDONA, AZ W HWY 89A (928) SEDONA, AZ CITY OF YUMA Yuma County 1401 S YUMA PALMS PKWY STE GO2 (928) YUMA, AZ S 4TH AVE (928) YUMA, AZ Visit for current provider information. Page 4
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