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

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