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Vision Benefit Schedule 

 

Vision coverage is provided at no additional cost to members enrolled in any of the state-sponsored health plans. All members and enrolled dependents have the same vision coverage regardless of the health plan selected.  Eye exams are covered once every 12 months from the last date the exam benefit was used.  All other benefits are available once every 24 months from the last date used.  Beginning July 1, 2014, replacement lenses, including contact lenses, will be available once every 12 months from the last date the benefit was used. Copayments are required.  For information regarding the vision plan, contact the plan administrator, EyeMed Vision Care at (866) 723-0512, (800) 526-0844 (TDD/TTY).

Service

Network Provider Benefit

Out-of-Network Provider Benefit**

Benefit Frequency

Eye Exam

FY2015 - $25 copayment
FY2014 - $20 copayment

$30 allowance

Once every 12 months

Spectacle Lenses*

(single, bifocal and trifocal)

FY2015 - $25 copayment
FY2014 - $20 copayment

$50 allowance for single vision lenses

$80 allowance for bifocal and trifocal lenses

Once every 24 months

Beginning 7/1/14, the benefit for lenses will be available every 12 months

Standard Frames (up to $175 retail frame cost; member responsible for balance over $175)

FY2015 - $25 copayment
FY2014 - $20 copayment

(for frames within the benefit selection)

$70 allowance

Once every 24 months

Contact Lenses

(All contact lenses are in lieu of spectacle lenses)

$120 allowance

$120 allowance

Once every 24 months

Beginning 7/1/14, the benefit for lenses will be available every 12 months

Lasik and PRK Vision Correction Procedures

15% off retail price or 5% off promotional price, whichever is the greater benefit

No Coverage

(available in-network only)

Unlimited

Low Vision Supplementary Testing

FY2015 - $25 copayment
FY2014 - $20 copayment

$125 allowance

Once every 12 months

Low Vision Aids

100% coverage after a 25% copayment with a $1,000 maximum allowance

100% coverage after a 25% copayment with a $1,000 maximum allowance

Once every 12 months

Spectacle Lenses:  Plan Participant pays any and all optional lens enhancement charges. Network providers may offer additional discounts on lens enhancements and multiple pair purchases.

** Out-of-network claims must be filed within one year from the date of service.

Updated 04/29/14