State of Michigan
Vision Benefit Plan for

Safety and Regulatory Unit A-02 (Group #81814)
Michigan State Employees Association (MSEA)

Labor and Trades Unit A-31 (Group #81817)
Michigan State Employees Association (MSEA)

State Police Troopers and Sergeants T-01 (Group #81816)
Michigan State Police Troopers Association (MSPTA)

Scientific and Engineering Unit H-21 (Group #81825)
Michigan Professional Employees Society (MPES)

Dear State Health Plan Member,

Enclosed is an updated version of your current vision benefits.

If you are a member of the State Health Plan ADVANTAGE, you already received a State of Michigan Employee Benefits binder (with the Health Care, Mental Health/Substance Abuse Care, and Prescription Drugs sections included). This section should be added to your binder under the Vision Care tab that came with your binder.

If you are not a member of the State Health Plan ADVANTAGE and receive your health benefits through another carrier, you, too, should have recently received a binder. If you have questions regarding your vision benefits, please call the BCBSM State of Michigan Customer Service Center at the numbers listed below.

Lansing area (517) 322-9515
In Michigan 1-800-643-4652
Toll free/Nationwide 1-800-843-4876

Sincerely,

Blue Cross Blue Shield of Michigan

Nonparticipating
Providers

Vision
Examination

Member copayment

Plan pays

$5

Payment in full*

$5

75% of the reasonable
and customary amount

Eyeglass frames
and medically
necessary
lenses

Member copayment (this copayment is only applied to either lenses or frames, not to both, at the time of purchase)

$7.50

-0-

Eyeglass frames

Plan pays

Up to $14

Regular glass lenses
(up to 71mm)

Single vision

Bifocal vision

Trifocal vision

Up to $13/pair

Up to $20/pair

Up to $24/pair

Plastic lenses

Payment in full*

Up to $3/pair additional

Prism lenses

Payment in full*

Up to $2/pair additional

Special lenses

Payment in full*

50% of the provider’s
charge
or
75% of the average
benefit paid to
participating providers
for comparable lenses,
whichever is less

Additional lens
expenses

Tints equal to
Rose #1 & #2

Payment in full*

Up to $3/pair

Contact lenses

Medically necessary

Not medically
Necessary

Payment in full*

Up to $90/pair

Up to $96/pair

Up to $40/pair

*BCBSM’s participating providers will accept the Plan’s "approved amount" as payment in full.

Out-of-state providers will also be reimbursed the BCBSM "approved amount" that they may or may not accept as payment in full.

This section describes your vision care benefits covered under a self-insured benefit plan administered by Blue Cross Blue Shield of Michigan (BCBSM) under the direction of the Office of the State Employer (OSE). Your benefits are not insured with Blue Cross Blue Shield of Michigan, but will be paid from funds administered by the OSE.

OSE is responsible for implementing State Health Plan Vision Care benefits and future changes in benefits. Blue Cross Blue Shield of Michigan will provide certain services on behalf of OSE through an administrative-service-only contract. Information concerning persons enrolled under the Vision Care Plan may be reviewed by Blue Cross Blue Shield of Michigan.

Please refer to the Health Care section of this benefit binder for additional information. If you have questions about your coverage that have not been answered in this section or the BCBSM Health Care section, please contact a Blue Cross Blue Shield of Michigan State of Michigan Customer Service Center representative.