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General Information
To help you reduce the costs associated with vision care, the Plan offers services through EyeMed Managed Vision Care, the Plan's vision network provider.
Covered vision expenses are the charges which you are required to pay for an eye examination performed by a licensed ophthalmologist or optometrist or for the lenses which are prescribed.
It is always your choice which provider to use, but you will receive a higher benefit if you use an EyeMed in-network provider is used. The Plan covers charges as specified below up to the maximum benefit levels once every calendar year.
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EYEMED
NETWORK PROVIDER
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OUT-OF-NETWORK
PROVIDER
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Eye Exam
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100% paid by Plan
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$30 per Calendar Year
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Lenses
(Single Vision, Bifocal, and Trifocal)
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100% paid by Plan
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$50 per Calendar Year
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Frames
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100% (up to $200 retail)
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$50 per Calendar Year
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Contacts
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100% (up to $125 retail)
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$75 per Calendar Year
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If a non-covered item is selected, the extra cost is your responsibility.
EyeMed Vision Care
1-800-334-7591
1. A vision claim in only needed for an out-of-network provider. A vision claim form is not required for in-network providers.
2. Tips on how to register online:
- Only one registration is needed per household. Each member of your family will share the same login information.
- When you register, be sure to enter the primary subscribers name exactly as it appears on your Medco drug ID card. For example, if your middle initial directly follows your first name or there is a period after your initial, enter your name exactly this way (i.e., John A. Smith would be entered exactly this way including the period, John A Smith would be entered as “John A” and then “Smith” as the last name.
- Use the last four digits of the primary subscribers social security number to register versus the Member ID.
Reimbursement of covered expenses will be made directly you. To file a claim, send the itemized bill, along with a vision claim form, directly to:
EyeMed Vision Care
Attention: OON Claims
P.O. Box 8504
Mason, OH 45040-7111
How to Obtain a Vision Claim Form for Out-of-Network Provider Claims
If you choose to use an out-of-network provider, your claim for benefit must include a claim form. You can contact either EyeMed Vision Care at 1-800-334-7591 or the Fund Office at 1-312-787-9455, Menu Option 3. Out-of-network claims must be filed with EyeMed Vision Care.
The exclusions listed below are not all-inclusive, and are representative only of the type of charges for which benefits are limited or not payable under the Plan.
1. Expenses for which benefits are payable under any Workers' Compensation Law.
2. Special procedures such as orthoptics or vision training and special supplies or non-prescription sunglasses and sub-normal vision aides.
3. Visual fields analysis which does not include refraction.
4. Vision surgery charges for correction of refractive errors and refractive Keratoplasly procedures including, but not limited to, radial Keratomy (RK), anterior lens Keratotomy (ALK), and laser in situ Keratomileusis (LASIK).
5. Vision expenses connected with disease or Non-Occupational (not worked) injury are covered under the Comprehensive Medical Benefits portion of the Plan.
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