IVSJPA: Vision Benefits Summary

Vision Benefit 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% to $210

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%
100%
100%

100% to $46
100% to $65
100% to $85
100% to $125

Limited to 1 pair of lenses per 12-month period.

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

 

Contact Form on ASI Schools Website

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