Next: Vision Plan Exclusions

State Police Enlisted Unit Benefit Booklet

STATE VISION PLAN GENERAL FEATURES

When you or a covered member of your family visit your participating provider, be sure to present your State Vision Plan (BCBSM-printed) identification card. The participating provider will complete and submit a claim form directly to BCBSM on your behalf. BCBSM will, in turn, send payment directly to the provider for all covered services. You pay the provider only your required copayment(s) and any amounts in excess of the Plan’s coverage limitations as shown in the Schedule of Vision Benefits chart at the beginning of this section.

If your vision care provider does not participate with Blue Cross Blue Shield of Michigan (BCBSM), benefits under the Plan will be payable directly to you. You will be responsible for paying your provider. For non-participating provider services, the Plan will cover the services described below only to the extent shown in the Schedule of Vision Benefits chart.

The Plan will cover the following vision care services after you or your enrolled family member has paid the provider any required copayment amount as shown in the Schedule of Vision Benefits chart.

Vision Testing Examinations

The Plan provides benefits for the following services once in every 12 consecutive months when they are performed by an optometrist or ophthalmologist:

• History
• Visual acuity (sharpness of vision) testing
• Internal and external examination of the eyes
• Tonometry (testing for glaucoma), when necessary
• Preparation of prescription for lenses

When recommended by an optometrist, the Plan also covers an additional examination by an ophthalmologist with respect to a vision problem, if the additional examination takes place within 60 days of the original examination by the optometrist.

BCBSM will pay participating providers in full. You are responsible for a $5 copay. If you receive services from a nonparticipating provider, the Plan pays 75 percent of the reasonable and customary amount less your $5 copay.

NOTE: 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.

Lenses, Frames and Dispensing Fees

The Plan provides benefits for prescribed lenses and/or frames once in every 24 consecutive months (or once in every 12 months if your prescription has changed):

• Eyeglass Lenses – The Plan provides a benefit for prescribed lenses of either glass or plastic. They must be first-quality lenses and meet the standards established by the Plan.

Lenses may be colorless or tinted with an ungraduated tint not exceeding Rose Tint #2.

Lenses are limited to a maximum diameter of 71mm. If a larger lens is selected, the cost of the extra size is your responsibility.

See the Schedule of Vision Benefits chart for the amount of your required member copayment, as well as the maximum benefits payable for regular lenses provided by either a BCBSM participating provider or a non-participating provider.

• Contact Lenses - The Plan provides a benefit for prescribed contact lenses of glass or plastic, if your vision cannot be corrected to at least 20/70 by other lenses or when medically necessary for certain specified medical conditions.

The Plan pays up to an allowable maximum level for medically necessary contact lenses. The maximum amount payable is shown in the Schedule of Vision Benefits chart. Charges exceeding the maximum amount payable under the Plan are your responsibility.

If contact lenses are selected, but they are not medically necessary for the reasons stated above, the Plan will pay an amount not exceeding the allowable maximum for both the lenses and the dispensing fee shown in the chart at the beginning of this section.

• Frames – The Plan provides a benefit for plastic, metal or wire eyeglass frames that are adequate to hold your prescribed lenses. The Plan pays up to an allowable maximum level, less your required member copayment of $7.50. The maximum amount payable for frames is shown in the chart at the beginning of this section. Charges exceeding the maximum amount payable under the Plan are your responsibility.
• Dispensing Fee – For BCBSM participating providers, the Plan covers the full cost of the usual dispensing fees for measuring and verifying lenses, as well as for selecting, fitting and adjusting the frames.

Next: Vision Plan Exclusions