How the Vision
Plan Works

Preferred Vision Providers

When you or your covered dependents need vision care,
call one of the preferred providers listed in your vision plan administrator directory to make an appointment and inform them that you are a City employee. See the Important Telephone Numbers and Web sites section of this handbook for more plan administrator information.

You will be asked to provide the social security number and birth date of the individual for whom the appointment is made. The provider will request authorization from the vision plan administrator and schedule your appointment. All claims will be filed by the provider.

All provider services must be approved by the vision plan administrator. If you change your mind and select another preferred provider after authorization has been given to a previous preferred provider, it is your responsibility to inform the vision plan administrator of the change.

Non-network Vision Providers

If you choose to go to a non-network vision provider, first call the vision plan administrator to confirm your eligibility and to request a claim form. Once you have received vision services from a non-network provider, you must file a claim form with the vision plan administrator to receive reimbursement.
You must also provide an itemized receipt of the services received. For more information about filing a claim, refer to "Filing Claims" on page VC-10.

All parts of the claim must be submitted at one time. You
may not split the benefits between a preferred and non-preferred provider. If you choose to use the preferred provider, you cannot get reimbursement for the cost of supplies or services received from a non-preferred provider within a benefit year.

A benefit year is the 12-month period from the date you last received vision services or supplies. Similarly, once you have chosen to be reimbursed for supplies or services received from a non-preferred provider, you will not be eligible to receive services from a preferred provider within the same benefit year.

What the Vision Plan Covers

Whether you choose a preferred provider or a non-network provider, the Vision Plan covers:

a vision exam once a year (there must be at least one full year between exams).

The plan covers eyeglasses or contact lenses more frequently than once every two years if a change in your prescription is medically necessary. Medical necessity is determined by Davis Vision's professional review committee. The plan may cover eyeglasses or contact lenses once a year if you have one of the following conditions:

progressive myopia/hyperopia;

diabetes;

developing cataracts;

keratoconus;

vision changes caused by prescription drugs; or

other conditions that could be reasonably expected to cause a significant change in refractive status.

For the plan to cover the annual cost of eyeglasses or
contacts, your provider must submit documented medical information to the plan administrator for review.

Vision Exams

Preferred Provider

If you go to a preferred provider, the plan covers the full cost of the exam.

Non-network Provider

If you go to a provider who is not a member of the network, the plan will pay a maximum of $25 for the cost of the exam; you pay the rest.

Lenses and Frames

Preferred Provider

The plan will generally pay the full cost of lenses and frames if you get them from a preferred provider. The plan covers the full cost of the following items:

plastic or glass lenses,

single vision lenses,

multifocal lenses,

glass gray #3 prescription lenses,

post-cataract lenses,

standard frames, and

oversized standard frames and lenses.

The plan requires a copayment for the following frames and optional services:

Davis Vision offers a one-year warranty against breakage on eyeglass frames and lenses supplied through their Central Laboratory and obtained from a preferred provider.

If you use a preferred provider, you are also able to recieve a discount of up to 20% for additional purchases such as frames, lenses and contact lenses.

Non-network Provider

The following maximum reimbursement amounts apply to services obtained from a provider who is not a member of
the network:

These fees also apply as allowances toward the receipt of materials received from a preferred provider which were not obtained from the Davis Vision Central Laboratory.

All other costs for vision services obtained from a non-network provider are your responsibility.

Contact Lenses

Preferred Provider

Standard Daily-wear Soft Contact Lenses - If you receive contact lenses from a preferred provider, you will pay $100 toward the cost of standard daily-wear soft contact lenses.
A care kit for cleaning and sterilization will be provided,
along with all office visits necessary for proper fitting of the contact lenses.

Other Types of Contact Lenses - If you select contact lenses other than the standard daily-wear soft lenses, you
will receive a $50 allowance toward the cost of the lenses and you will pay any balance after a 20% discount (excluding disposable contacts) has been applied. For example, if you purchase contact lenses that cost $250, your $50 allowance is applied to the $250. Your balance is $200 and you will receive a 20% discount on the balance. In this example, the 20% discount equals $40 which is deducted from $200; you would pay $160.

Note: You will not receive the 20% discount if you purchase disposable contact lenses.

Non-network Provider

If you obtain contact lenses from a non-network provider, the plan will pay a maximum of $50 toward the cost of the lenses. All other costs for services obtained from a non-network provider are your responsibility.

Replacement lenses and contact lens insurance are not covered by the Vision Care Plan.

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