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Skip Navigation LinksHome » Health Benefit Info Active » Vision  
 

General Information

To help you reduce the costs associated with vision care, the Plan offers services through EyeMed Managed Vision Care, the Plan's vision network provider.  
 
Covered vision expenses are the charges which you are required to pay for an eye examination performed by a licensed ophthalmologist or optometrist or for the lenses which are prescribed.
 
It is always your choice which provider to use, but you will receive a higher benefit if you use an EyeMed in-network provider. The Plan covers charges once every calendar year.
 
VISION CARE BENEFITS
Contracted Network Provider:  EyeMed Vision Care

 

EyeMed In-Network Provider 
 
(Participant’s Cost)

 
Out-of-Network Provider
  
 (Maximum Amount Plan Pays)
Frequency
  • Exam
  • Lenses or Contacts
  • Frame

Once per calendar year

Eye Exam Co-Pay (with dilation, if necessary)

$0 Co-Pay

  • Covered Individuals through Age 18:  Plan pays 20%
  • Covered Individuals Age 19 and older:  Plan pays $30
Exam Options Co-Pay:
  • Standard Contact Lens Fit and Follow-up
  • Premium Contact Lens Fit and Follow-up
 
 
Up to $40 Co-Pay
 
10% off Retail
 
 
 
No coverage
Frames Allowance (any available frame at provider location):
  • Frames up to $200
  • Frames over $200

 

 
 
  
$0 Co-Pay
20% off balance over $200
  
  
  
   
   
    Plan pays $50
 
Standard Plastic Lenses
  • Single vision
  • Bifocal
  • Trifocal
  • Standard progressive lens
  • Premium progressive lens
        – Tier 1
        – Tier 2
        – Tier 3
        – Tier 4

 

 
 
$0 co-pay
$0 co-pay
$0 co-pay
$65 co-pay
 
 
$85 co-pay
$95 co-pay
$110 co-pay
$65 co-pay, 80% of charge of the lenses, less $120 allowance
 
  
 
  
 
  
   
   
    Plan pays $50
 
Lens Options
  • UV Treatment
  • Tint (solid and gradient)
  • Standard plastic scratch coating
  • Standard polycarbonate – adults
  • Standard polycarbonate – kids under 19
  • Standard anti-reflective coating
  • Premium anti-reflective coating
  • – Tier 1
    – Tier 2
    – Tier 3
  • Polarized
  • Photochromic/transaction plastic
  • Other add-ons
 
 
$15 co-pay
$15 co-pay
$15 co-pay
 
$40 co-pay
 
$40 co-pay
 
$45 co-pay
 
 
 
$57 co-pay
$68 co-pay
80% off charge
20% off retail price
$75 co-pay
 
20% off retail price
 
  
 
  
 
  
   
   
    No Coverage
 
Contact Lenses (material only)
  • Conventional
  •  
     
     
  • Disposable
  •  
     
     
  • Medically Necessary
 
 
Up to $125 = $0 co-pay. 15% off balance over $125
Up to $125 = $0 co-pay, plus the balance over $125
 
$0 Co-pay
 
 
Plan Pays $75
 
 
 
Plan Pays $75
  
 
 
Plan pays $200
Additional Pairs
40% discount off complete pair eyeglass purchase and a 15% discount off conventional contact lenses once the funded benefit has been used
No Coverage
       

 If a non-covered item is selected, the extra cost is your responsibility.

 
EyeMed Vision Care
1-800-334-7591
 
1.      A vision claim form is only needed for an out-of-network provider. A vision claim form is not required for in-network providers. 
 
2.      Tips on how to register online:
  • Only one registration is needed per household. Each member of your family will share the same login information.
  • When you register, you will be asked for the member's name, date of birth, the last four digits of the social security number, or the Member ID. Your user ID will be your email address.
Reimbursement of covered expenses will be made directly you. To file a claim, send the itemized bill, along with a vision claim form, directly to:
 
EyeMed Vision Care
Attention: OON Claims
P.O. Box 8504
Mason, OH 45040-7111
 
How to Obtain a Vision Claim Form for Out-of-Network Provider Claims
If you choose to use an out-of-network provider, your claim for benefits must include a claim form. You can contact either EyeMed Vision Care at 1-800-334-7591 or the Fund Office at 1-312-787-9455, Menu Option 3. Or you can log on to their website (instructions above) and download a claim form. Out-of-network claims must be filed with EyeMed Vision Care.
 
The exclusions listed below are not all-inclusive, and are representative only of the type of charges for which benefits are limited or not payable under the Plan.
 
1.     Expenses for which benefits are payable under any Workers' Compensation Law.
 
2.     Special procedures such as orthoptics or vision training and special supplies or non-prescription sunglasses and sub-normal vision aides.
 
3.     Visual fields analysis which does not include refraction.
 
4.     Vision surgery charges for correction of refractive errors and refractive Keratoplasly procedures including, but not limited to, radial Keratomy (RK), anterior lens Keratotomy (ALK), and laser in situ Keratomileusis (LASIK).
 
5.     Vision expenses connected with disease or Non-Occupational (not work related) injury are covered under the Comprehensive Medical Benefits portion of the Plan.

 

 

 
 

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