IVSJPA: Vision Benefits Summary
Network and Non-network providers
The Plan Sponsor has contracted with an organization or “Network” of vision providers. The Network is Medical Eye Services (MES). Network providers have agreed to provide care at negotiated rates. Lists or directories of the Network providers will be given to Plan participants without charge.
When obtaining vision care services, a Covered Person has a choice of using a provider who is participating in the Network or any other Covered Provider of his choice (a Non-Network provider).
Since Network providers have agreed to provide services to Covered Persons at negotiated rates, when a Covered Person uses a Network provider his out-of-pocket costs may be reduced because he will not be billed for expenses in excess of “Usual, Customary and Reasonable”. The Schedule of Vision Benefits (below) may also include other benefit incentives to encourage Covered Persons to use Network providers whenever possible.
Schedule of Vision Benefits
| ELIGIBLE VISION EXPENSES |
MES Network |
Non-Network |
| Eye Examination |
100% |
100% to $40 |
| Limited to 1 exam per 12-month period. | ||
| Contacts (in lieu of glasses) |
100% |
100% |
|
Benefits for necessary contacts are limited to $210 and are available every 12-month period. “Necessary” contacts are those: (1) following cataract surgery, (2) when visual acuity cannot be corrected to 20/70 in the better eye except through the use of contacts or (3) necessitated by anisometropia or certain conditions of keratoconus. Benefits for other contacts are limited to $105 per 24-month period. |
||
| ELIGIBLE VISION EXPENSES |
MES Network |
Non-Network |
| Frames, per pair |
100% to $250 |
100% to $125 |
| Limited to 1 standard frame per 24-month period. A “standard” frame is any frame with a retail cost of $250 or less. | ||
| Lenses for Glasses Single Vision Bifocals Trifocals Lenticular |
100% |
100% to $46 |
| Limited to 1 pair of lenses per 12-month period. | ||
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Forms
All forms necessary for enrolling, making changes, or filing a claim are available at your fingertips:
P.O. Box 5809
Fresno, CA 93755
(866) 777-1320 Phone
(559) 475-5780 Fax