Overview of Vision Plan
The Vision Plan is designed to provide for standard vision examinations and eyewear materials such as eyeglasses or contact lenses. Vision benefits are administered by an independent Vision Plan Claims Administrator whose name and address are listed on the Quick Reference Chart and in the Summary Plan Description (SPD)/Plan Document.
Eligibility For Vision Plan Benefits
You and your eligible dependents are eligible for vision benefits on the date your medical Plan benefits become effective.
The Vision Plan contracts with an independent network of vision providers who extend a discount to you for covered vision services. Covered vision expenses are noted in the Schedule of Vision Benefits.
Network providers have a contract to provide discounted fees to you for services covered under this Vision Plan.
Steps for using a Network provider are as follows:
Call any participating doctor to make an appointment. Identify yourself as a member of the Vision Plan and provide your member identification number (usually the last 4 digits of the Social Security Number of the Employee) and the name of the group Plan (District Council 16 Northern California Health and Welfare Trust Fund).
If you need assistance locating a participating doctor, call the Vision Plan at the number listed on the Quick Reference Chart or log on to the Vision Plan website www.vsp.com and use the ―Find a doctor feature.
After you have scheduled an appointment, the participating doctor will contact the Vision Plan to verify your eligibility and coverage.
When you go for your visit, if you receive new lenses or frames you should pay the participating vision provider your copayment and charges for any costs not covered (see What is Covered, Optional Extras, and Exclusions from Coverage below.
NOTE: You must identify yourself as a member of this Vision Plan at the time that you make the appointment with the in-network provider or you may not receive the in-network discounted rates.
You may choose to use a Non-Network provider (any licensed and qualified vision care provider) instead of a Network provider. However, your benefits will then be limited to the applicable reimbursement allowances (after the copayment).
If you use a Non-Network provider, you will need to pay the doctor in full at the time of your visit. You may then file a claim with the Vision Plan for reimbursement according to a fixed schedule, which will not cover all of your vision expenses.
Vision Plan Exclusions
The following is a list of services and supplies or expenses not covered (excluded) by the Vision Plan. The Plan Administrator, and other Plan fiduciaries and individuals to whom responsibility for the administration of the Vision Plan has been delegated, will have discretionary authority to determine the applicability of these exclusions and the other terms of the Plan and to determine eligibility and entitlement to Plan benefits in accordance with the terms of the Plan.
- Vision services and supplies that cost more than the Plan’s allowance as noted in the Schedule of Vision Benefits.
- Lenses and frames furnished under this program, which are lost or broken, will not be replaced except at the normal intervals when services are otherwise available as described in the Schedule of Vision Benefits.
- Glasses secured when there is no prescription charge, such as reading glasses obtained from a drugstore.
- Medical or surgical treatment of the eyes, including, but not limited to, refractive keratoplasty (RK) or laser assisted in situ keratoplasty (LASIK) except that this Vision Plan does offer a discount on laser eye surgery when performed by In-network Vision providers.
- Services or materials provided as a result of any Workers’ Compensation Law, or similar occupational health legislation or obtained through or required by any government agency or program, whether federal, state or any subdivision thereof.
- Services or supplies received for an illness that is a result of war, whether declared or undeclared.
- Experimental and/or investigational treatment or procedure.
- Benefits incurred beyond the termination date of the Plan, unless COBRA coverage is in place.
- Expenses related to complications of a non-covered service.
Filing a Vision Claim/Appealing a Denied Claim
NOTE: The discussion below applies to “post-service claims” claims you submit after you have received a service. Requests for required pre-authorization to have contact lenses covered as necessary are also considered claims. See Appeals for more information. If you use a Network provider, you will not need to file a claim form. You will pay your copayment at the end of your visit, and your provider will take care of billing the Vision Plan for the remainder.
If you use a Non-Network provider, you will need to file a claim for reimbursement of the applicable amount(s). Call the Vision Plan at the phone number listed on the Quick Reference Chart to have a Non-PPO Reimbursement Form mailed or faxed to you (you can also fill out the form online and print it out). Mail the completed form with your itemized receipt to Vision Plan at the address listed on the Quick Reference Chart.
NOTE: You must submit your claim within 180 days from the date on which covered expenses were incurred. Benefits will not be allowed if you submit your claim more than 180 days after the date on which covered expenses were incurred.
If you have any questions about submitting your claim, contact the Vision Plan.
For information on what to do if you disagree with the decision made in regard to your claim, see Appeals.
|Covered Vision Benefits||Explanations and Limitations
See also the Vision Plan Exclusions section.
||100% after a
|After a $20 copay the Plan pays 100%,
not to exceed
$43 per exam.
|Frames for Eyeglasses||
||100% after a
$20 copay up to the Plan allowance. If you choose a frame whose cost exceeds the Plan allowance, you will be responsible for the additional cost.
|After a $20 copay, Plan pays
100% to a maximum of $40.
|Lenses for Eyeglasses||
||Single Vision (Standard): 100%
|After a $20 copay the Plan pays:
Single Vision: 100%, up to $26
Bifocals: 100%, up to $43.
Trifocals: 100%, up to $60
100% up to $100
If only one lens is needed, the allowance will be one-half the pair allowance.
Contact Lenses will be considered Medically Necessary if you obtain prior authorization from the Vision Plan.
Your eye care provider will need to furnish VSP with the information it needs to decide whether contact lenses are necessary for you. VSP providers will have a prior authorization form they can use for this purpose. Non-VSP providers should contact VSP to find out what is needed.
Once a request for prior authorization is received (assuming it has all the required information), a decision is generally made within 3 to 5 days.
If VSP decides contact lenses are not necessary for you, you may appeal the decision as explained in Appeals. You also have the option of having your lenses covered as elective contact lenses instead.
(not medically necessary):
100% after a
$20 copay, up to
$130 for the contact lens fitting and evaluation as well as materials. Contact Lenses
100% after a
(not medically necessary):
100%, up to $43 for the comprehensive exam and up to $100 for the contact lens fitting and evaluation as well as materials.Contact Lenses
After a $20 copay, 100%, up to $45 for the exam and up to $210 for materials and other fees.
|Low Vision Benefit
The Plan includes a low vision benefit for severe vision problems not corrected with regular lenses.
|Benefits under this Plan include, but are not limited to:
||Contact the Vision Plan
for more information
on available benefits.
In addition to the benefits stated above, members are eligible for the following with a Network Provider:
(for all Active and Retired Employees and their eligible Dependents)
|Vision Service Plan (VSP)
3333 Quality Drive
Rancho Cordova, CA 95670
Toll Free: 1-800-877-7195
To file a Non-PPO Claim for reimbursement, send it to the following address:Vision Service Plan (VSP)
Attn: Out-of-Network Provider Claims
P.O. Box 385018
Birmingham, AL 35238