Generally, expenses claimed under the Vision Care Benefit are subject to a two-year eligibility cycle that begins every odd year, meaning that the stated maximum eligible expense is for two calendar years instead of one. A new cycle began in 2017, and the next will begin in 2019.
The Vision Care Benefit provides 80% reimbursement for the reasonable and customary charges of the following expenses based on this two-year cycle:
Eligible expenses with two-year cycle
Eye examinations by an optometrist, limited to one examination every two calendar years, commencing every odd year.
Eyeglasses and contact lenses that are necessary for the correction of vision and are prescribed by an ophthalmologist or optometrist, and repairs to them, limited to a maximum eligible expense of $275 every two calendar years, commencing every odd year
Eligible expenses where two-year cycle does not apply
Artificial eyes and replacements thereof, but not within:
- 60 months of the last purchase in the case of a member or dependant over 21 years of age, or
- 12 months of the last purchase in the case of a dependant 21 years of age or less,
unless medically proven that growth or shrinkage of surrounding tissue requires replacement of the existing prosthesis.
The initial purchase of intraocular lenses, eyeglasses, or contact lenses necessary for the correction of vision and required as a direct result of surgery or an accident where the purchase is made within six months of such accident or surgery.
This benefit is not subject to any limits other than reasonable and customary charges.
The six-month time limit may be extended if, as determined by the Administrator, the purchase could not have been made within the time frame specified.
Lifetime maximum of $1,000 (reimbursed at 80%) per plan participant.
Surgery must be performed on or after October 1, 2014, to be eligible.
Surgery must be performed by an ophthalmologist. A physician’s prescription is not required.
No benefit is payable for:
- Expenses identified in the General Exclusions and Limitations of the Plan