Page 16 - Optima Tax EE Guide 01-19 AZ.pub
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Vision Plan








         Blue Shield | Vision Plan
         Optima Tax Relief provides vision coverage through Blue Shield. You can see an Blue Shield in-network provider or
         an out-of-network provider, however, your costs will be lower if you visit an in-network provider. If you visit an in-
         network provider you will be responsible for a copay at the time of your service. If you receive services from an out
         -of-network doctor, you will pay all costs at the time of service and submit a claim for reimbursement.

                                                                            Blue Shield
         Plan Name                                                             PPO

         Network Name                                     Vision PPO                       Non-Network
         Vision Benefits
         Copay
          - Examination                                    $15 Copay                             N/A
          - Materials                                      $25 Copay                             N/A
         Examination (Every 12 Months)
          - Ophthalmologic                                 No Charge                  Up to $60 Reimbursement
          - Optometric                                     No Charge                  Up to $50 Reimbursement

         Lenses (Every 12 Months)
          - Single Vision                                  No Charge                  Up to $43 Reimbursement
          - Bifocal                                        No Charge                  Up to $60 Reimbursement
          - Trifocal                                       No Charge                  Up to $75 Reimbursement
          - Lenticular or Aphakic Monofocal                No Charge                  Up to $120 Reimbursement
          - Lenticular or Aphakic Multifocal               No Charge                  Up to $200 Reimbursement
          - Polycarbonate (Children)                      $100 Benefit                 Up to $75 Reimbursement
          - Progressive (No-Line Bifocals)                $140 Benefit                 Up to $100 Reimbursement
          - Anti-reflective Coating                        $50 Benefit                  Up to $35 Reimbursement
          - Photochromic Lenses                        $115-$200 Benefit             Up to $85-150 Reimbursement
         Frames (Every 24 Months)                         $130 Benefit                 Up to $40 Reimbursement
         Contact Lenses (Every 12 Months)                           (in lieu of frames and lenses)
          - Cosmetic / Elective                           $120 Benefit                 Up to $120 Reimbursement
          - Medically Necessary - Hard                     No Charge                  Up to $200 Reimbursement
          - Medically Necessary - Soft                     No Charge                  Up to $250 Reimbursement
         Supplemental Low-Vision Testing/                     75%                            Not Covered
         Equipment Covered up to $1,000
         Non-Prescription Sunglasses                      $130 Benefit                        Not Covered
         Diabetes Management Referral                      No Charge                         Not Covered




            Finding a Vision Provider
            Go to www.bluehsieldca.com. When prompted to enter a plan type,
            select “Vision Plans (Individual and Family Group Plans)”

            Blue Shield’s network includes access to more than 29,000 eyecare
            practitioners nationwide including independent ophthalmologists
            and optometrists, as well as Costco, Walmart, LensCrafters, Site for
            Sore Eyes, For Eyes Optical, and Target Optical retail stores.







    16  Employee Benefits
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