FCA - Stellantis Represented Employees Client Details

(AKA Fiat Chrysler Automotive or Chrysler Stellantis)

FCA - Stellantis Represented Employees receive the following custom benefit provisions:

$7.50 Copay applies to ECL

15% Discount off CL Materials Overages

Interim Benefits for Myopia Management of Dependent Children
Interim Benefits for Type 1 Diabetics

And for the HBU, and NTC Active Unions only, they also access to the Preferred Laser Vision Care benefit every four years.

Contact Lens Benefit

Patients have an Exam And $90 Contact Lens Allowance with a $7.50 copay plus a 15% discount off contact lens material overages.

Elective Contact Lens Copayment Exception

This client requires subtracting their $7.50 copay from the total charged, rather than from the contact lens allowance. Subtract copay from total of discounted fitting, evaluation and U&C material charge. Follow instructions below.

How to Calculate Patient’s Contact Lens Professional Fees and Materials Out-of-Pocket Costs

First, did the patient receive any contact lens professional services? If no, skip to section: example when only materials are provided.

If yes, then determine whether your total charges (85% of U&C fitting & evaluation plus materials) is more or less than the patient’s $90 contact lens allowance. Then follow the corresponding example within section: examples when both professional services and materials are provided.

Examples – When only Materials are Provided

1. Determine your U&C material charge and subtract $7.50 copay.
Your U&C fee for contact lens materials:	$150
Patient’s copay:	- $7.50
Remaining balance:	$142.50
2. Subtract the $90 contact lens allowance from the remaining balance.
Contact lens allowance:	-$90
Contact lens materials overage:	$52.50
3. Deduct 15% from any Contact Lens materials overage.
Remaining overage:	$52.50
15% materials discount:	-$7.87
Final Patient Out-of-Pocket Cost:	$44.63

Examples - When both Professional Services and Materials are Provided

Remaining balance is less than Contact Lens $90 Allowance
1. Subtract the $7.50 copay from your Total Fess to determine the remaining balance.
Total Fees (Professional Services and CL Materials): Patient's copay:	$80 -$7.50
Remaining balance:	$72.50
2. Subtract the $90 contact lens allowance from this total.
Contact lens allowance	-$90
Final balance due:	$0
Remaining balance is more than Contact Lens $90 Allowance
1. Subtract the $7.50 copay from your professional fees.
85% of your U&C fee for fitting and evaluation: Patient’s copay:	$30 -$7.50
Remaining professional fee balance:	$22.50
2. Subtract the professional fee balance from the $90 contact lens allowance from professional fee balance.
Contact lens allowance:	$90
Remaining professional fee balance:	-$22.50
Remaining contact lens allowance:	$67.50
3. Subtract remaining contact lens allowance from U&C materials.
Your U&C fee for contact lens materials:	$150
Remaining contact lens allowance:	-$67.50
Contact Lens Materials Overage:	$82.50
4. Deduct 15% from any Contact Lens materials overage.
Remaining overage:	$82.50
15% materials discount:	-$12.37
Final Patient Out-of-Pocket Cost:	$70.13

Remaining balance is less than Contact Lens $90 Allowance

1. Subtract the $7.50 copay from your Total Fess to determine the remaining balance.

Total Fees (Professional Services and CL Materials):

Patient's copay:

$80

-$7.50

Remaining balance:

$72.50

2. Subtract the $90 contact lens allowance from this total.

Contact lens allowance

-$90

Final balance due:

$0

Remaining balance is more than Contact Lens $90 Allowance

1. Subtract the $7.50 copay from your professional fees.

85% of your U&C fee for fitting and evaluation:

Patient’s copay:

$30

-$7.50

Remaining professional fee balance:

$22.50

2. Subtract the professional fee balance from the $90 contact lens allowance from professional fee balance.

Contact lens allowance:

$90

Remaining professional fee balance:

-$22.50

Remaining contact lens allowance:

$67.50

3. Subtract remaining contact lens allowance from U&C materials.

Your U&C fee for contact lens materials:

$150

Remaining contact lens allowance:

-$67.50

Contact Lens Materials Overage:

$82.50

4. Deduct 15% from any Contact Lens materials overage.

Remaining overage:

$82.50

15% materials discount:

-$12.37

Final Patient Out-of-Pocket Cost:

$70.13

Note:

Our online Savings Statement will not automatically calculate copays or overages for ECL members of this client.

Interim Benefits

The FCA - Stellantis Represented Employees have the following interim benefits when benefit criteria are met:

Interim Benefits for Type 1 Diabetics

Insulin-dependent diabetics (Type 1) will be eligible for an eye exam every January 1 after last eligible exam covered by the vision plan with a $5 copay. If the exam reveals a prescription change of .50 diopter or more and/or 10 degrees of axis change or more, new lenses will be provided with a $7.50 copay according to vision benefits provided by the plan annually. Ensure you indicate your patient’s Type 1 diabetes in their chart.

Interim Benefits for Dependent Children with Progressive Myopia Management

Dependent children up to their 19th birthday are eligible to receive a yearly exam with a $5 copay and new lenses, subject to a $7.50 copay with a prescription change of a -.50 diopter or more for.

Preferred Laser Vision Care

(For HBU, SBU and NTC Active Unions only)

Total (both eyes) allowance of $350 once every four years, instead of prescription eyewear.

LVC Allowance Exception

Divisions 3001 – 3006 only - In addition to using their material benefit for prescription eyewear (including lens, frame, and contact lenses), eligible patients may use their benefit toward approved Laser Vision Care (LVC) services (LASIK, Custom LASIK, Bladeless LASIK, PRK, Custom PRK, SMILE or Contoura).

Eligible patients will have a $350 total LVC allowance available once every four (4) plan years. The allowance amount applies to both eyes. The patient may be eligible for materials, in addition to LVC services. The patient will still be eligible for the standard LVC discounts.

Please note: eligibility may not show online. Contact VSP to confirm and/or receive authorization.

Authorization

To receive an authorization for either Interim Benefits or Preferred Laser Vision Care, contact VSP.

Questions

For assistance concerning these custom benefits, contact VSP at 800.615.1883.

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