State Vision Plan

EyeMed administers the vision benefits for the State Employee's Group Insurance Program. When plan participants utilize a network provider, the benefit levels are greater. Services provided by an out-of-network provider are paid at a lower benefit level.

Plan participants must submit an EyeMed Claim form (PDF 80 KB) for reimbursement when an out-of-network provider is used.

 FY21 Plan Year

ServiceIn-Network​​Out-of-Network​**Frequency​
Eye Exam​$30 copayment​$30 allowance​Once every 12 months
Standard Frames

​$30 copayment (up to $175 retail frame cost; member responsible for balance over $175)

$70 allowance
Once every 24 months​
Vision Lenses*
(single, bifocal and trifocal)
​$30 copayment
 

​$50 allowance for single vision lenses

$80 allowance for bifocal and trifocal lenses
​Once every 12 months
Contact Lenses
(all contact lenses are in lieu of spectacle lenses)
​$120 allowance​$120 allowance​Once every 12 months
 * VisionLenses: Member pays any and all optional lens enhancement charges. In-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.

 

Reviewed 04/30/2020