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LGHP Vision Plan
Vision coverage is provided at no additional cost to members enrolled in any of the LGHP health plans. All members and enrolled dependents have the same vision coverage regardless of the health plan selected. All vision benefits are available once every 12 months from the last date used, with the exception of frames and lenses, which are available once every 24 months. Copayments are required.
The plan administrator for the vision benefit is EyeMed. Requests for reimbursement for services provided by an out-of-network vision provider must be submitted on an EyeMed claim form [PDF, 134KB].
FY2024 Plan Year
| Service | In-Network | Out-of-Network** | Frequency |
|---|---|---|---|
| Eye Exam | $25 copayment | $30 reimbursement | Once every 12 months |
Standard Frames
|
$25 copayment ($175 allowance; 20% off balance over $175 | $70 reimbursement
|
Once every 24 months |
Vision Lenses* |
$25 copayment
|
$50 reimbursement for single vision lenses $80 reimbursement for bifocal and trifocal lenses
|
Once every 12 months |
New added benefit effective 7/1/2023 (in lieu of above lens benefit) Progressive Lenses*** (Includes Lens Copay) |
Standard Progressive - $90 copayment Premium Progressive Tier 1 - $110 copayment Tier 2 - $120copayment Tier 3 - $135copayment Tier 4 - $90 copayment, 80% of charge less $120 allowance |
$80 reimbursement | Once every 12 months |
New added benefit effective 7/1/2023 Anti-Reflective Coating*** |
Standard - $45 copayment Premium Anti-Reflective Coating Tier 1 - $57 Tier 2 - $68 Tier 3 – 80% of charge |
N/A | N/A |
| New added benefit effective 7/1/2023 – Additional Lens Add- On’s | Photochromic (Plastic) - $75 Polarized – 80% of charge |
N/A | N/A |
| Contact Lenses (all contact lenses are in lieu of spectacle lenses) |
|||
| Conventional | $120 allowance, 15% off balance over $120 | $120 reimbursement | Once every 12 months |
| Disposable | $120 allowance; plus, balance over $120 | $120 reimbursement | Once every 12 months |
| Medically Necessary | $0 Copay; paid in full | $120 reimbursement | Once every 12 months |
* Vision Lenses: Member pays all optional lens enhancement charges unless specified above. In-Network providers may offer additional discounts on lens enhancements and multiple pair purchases.
** Out-of-network claims must be filed within 15 months from the date of service.
*** Fixed pricing is reflective of brands at the listed product level. All providers are not required to carry all brands at all levels.
EyeMed Vision Care reserves the right to make changes to the products on each tier and the member out-of-pocket costs.