Agencies
Services
State Vision Plan
EyeMed administers the vision benefits for the State Employee's Group Insurance Program. When plan participants utilize a network provider, the benefit levels are greater. Services provided by an out-of-network provider are paid at a lower benefit level.
Plan participants must submit an EyeMed Claim form for reimbursement when an out-of-network provider is used.
FY2024 Plan Year
| Service | In-Network | Out-of-Network** | Frequency |
|---|---|---|---|
| Eye Exam | $30 copayment | $30 reimbursement | Once every 12 months |
Standard Frames
|
$30 copayment (up to $175 retail frame cost; 20% balance over $175 allowance) | $70 reimbursement
|
Once every 24 months |
| Vision Lenses* (single, bifocal and trifocal) |
$30 copayment
|
$50 reimbursement for single vision lenses $80 reimbursement or 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 - $95 copayment Premium Progressive Tier 1 - $115 copayment Tier 2 - $125 copayment Tier 3 - $140 copayment Tier 4 - $95 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; plus 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.