Tri-State Plan SPD >> Vision Care Benefits

• Overview
• Eligible Expenses
• Excluded Expenses

If you need an eye exam, corrective lenses (including contact lenses) or frames, you can go to a participating provider or a non-participating provider. By using a participating provider, you can get an exam and glasses with no out-of-pocket cost, but your choice of frames will be limited. If you want frames and/or lenses that cost more than the Plan's limit, you will pay the difference.

If you use a non-participating provider, you can get up to $30 for eye exams, $60 for lenses and $60 for frames. Or you can receive up to $120 for contact lenses as a substitute for the lenses and frames. You will be responsible for paying the charges in full and will be reimbursed up to the allowed amounts.

These maximum benefits are payable within any 24-month period, starting with the date you first incur a vision care expense (typically an eye exam). For example, if you get an eye exam on September 1, 2005, you have up to September 1, 2007 (assuming you remain eligible for Fund benefits) to receive the benefits cited above for the lenses and frames or contacts. Any unused vision care benefits cannot be carried over and used in a subsequent 24-month period.
You can access your Vision Plan benefits by:

• showing your Empire ID card to a Vision Plan participating provider. The Plan has 4 participating providers: Comprehensive Professional Systems, Davis Vision, General Vision Services ("GVS") and Vision Screening, or

• visiting a non-participating provider and later submitting a Vision Plan claim form to the Fund for reimbursement.

Each participating provider has many office locations throughout the metropolitan New York/New Jersey area. Some providers also have office locations outside New York and New Jersey. You can select the participating provider that is most convenient to you. You cannot switch back and forth between participating providers within a 24-month period. For example, if you use Davis Vision for your exam and you receive a prescription for glasses or contacts, you must also use Davis to receive your frames and lenses within the 24-month period. (You could use different providers within Davis for the exam and the glasses, as long as both providers are part of Davis.) Also, each member of your family can use a different participating provider if they wish.
You can switch back and forth between non-participating providers.

To find a participating provider, call 11-800-551-32BJ.

Eligible Expenses

The Plan covers the following vision care expenses:

• eye examinations performed by a legally qualified and licensed ophthalmologist or optometrist

• prescribed corrective lenses you receive from a legally qualified and licensed optician, ophthalmologist or optometrist.

Excluded Expenses

The Plan's vision care coverage will not reimburse or make payments for expenses incurred for, caused by, or resulting from:

• expenses incurred for ophthalmic treatment or services payable under the provisions of any other benefit of the Plan (see your hospital/medical plan for eligible ophthalmic treatment)

• non-prescription eyeglasses

• adornment expenses.