Active Employee Plan Only
Payment of Vision Benefits
If a covered person incurs covered vision expenses, benefits will be payable up to the maximum benefit allowable for a particular service or supply during the time period stated on the Schedule of Benefits, subject to the provisions and limitations stated below.
To be considered “covered vision expenses,” charges for services and supplies must be provided by an optometrist or an opthalmologist who is legally qualified and licensed to practice his trade or profession by the appropriate governmental authority and who is performing services within the scope of his specialty.
Covered Vision Expenses
Covered vision expenses include the reasonable and customary charges made for the following:
- Examination – A complete visual analysis once in a calendar year, including case history and refraction and the prescription of glasses where indicated. Benefits are payable only when eye refraction is performed.
- Lenses – Up to two lenses per calendar year. During any one year, you can receive eyeglass lenses or contact lenses, but not both.
- Frame – One frame per calendar year.
- Contacts – The Plan will pay up to the contact lense allowance on the Schedule of Benefits for contact lenses received in lieu of eyeglasses. Only one allowance is payable each year, even if you purchase multiple sets of contacts in a year. The Plan will not pay the contact lens allowance and the eyeglass allowance in the same calendar year.
Vision Benefit Exclusions and Limitations
- Supplies that were ordered while a person was not covered under this Plan.
- Services or supplies for which benefits are payable under the Comprehensive Benefit; or for medical or surgical treatment.
- Duplicate or spare eyeglasses, lenses or frames; or two pair of glasses in lieu of bifocals; or replacement of lost, stolen or broken lenses and/or frames which are furnished under this Plan, except at the normal intervals when such services and supplies are otherwise available.
- Special procedures, such as orthoptics or vision training; or special supplies, such as subnormal vision aids; or any professional services or materials connected with aniseikonic lenses, multifocal plastic lenses, coated lenses, no-line bifocals (blended type), non-prescription lenses, or plain or prescription sunglasses (tinted lenses with a tint higher than #2 are considered sunglasses).
- Any eye examination required: (a) by an employer as a condition of employment which the employer is required to provide under the terms of the labor agreement; or (b) by a government body.
- More than one visual analysis during a calendar year, or for more than two lenses during a calendar year, or for more than one frame during a calendar year.
- Charges in excess of any maximum benefit stated on the Schedule of Benefits.
- Any services, supplies or types of treatment for which no benefits are payable under the Plan as a whole as stated in the “What the Plan Does Not Cover” section.