Vision Plan Synopsis

Vision Plan Synopsis

  Port Jefferson Station Teachers Association

VISION:   General Vision Services

PLAN YEAR:   July 1st through June 30th

IN-NETWORK  Benefits once per plan year

A.  Comprehensive Eye Exam No Charge

B.  Selection of Various Frames No Charge

Up to retail of $200 GVS Collection

C.  Selection of Lenses No Charge

a.  Single

b.  Conventional Bifocal

c.  Conventional Trifocal

d.  GVS Standard Progressive

D.  Contacts No Charge

a.  Standard contacts

b.  Disposable (12month supply/Cooper-$200 credit all others)

Surcharges

Polycarbonate Stock Lenses

Single Vision: NC

Bifocal: $  55.00

Transition III

Single: $  97.00

Bifocal: $131.00

GVS Progressive: $175.00

High Index Transition III

Single Vision: $144.00

Bifocal: $160.00

GVS Progressive : $212.00

Polarized Lenses

Single Vision: $  60.00

All frame upgrades from the GVS collection received $200 credit.  All other frames receive $150 credit towards any amount purchased.

Loss Protection Program is included in the program – This program allows for replacement of benefits package for a co-pay of $25, no questions asked.

LASIK Surgery Benefit 

Coverage through GVS entitles members and their dependents that are eligible at time of services for benefits of LASIK surgery.  The available LASIK Benefit contributes $500 per eye towards any LASIK corrective surgery.  General Vision utilizes Long Island Surgical for LASIK procedures; however, the member is not required to utilize Long Island Surgical.  Discounts have been negotiated with Long Island Surgical in addition to the payments made by GVS to the provider.

OUT OF NETWORK FEE SCHDULE  –  1/1/2011

Exam: $  30.00

Frame: $  30.00

Lens: Single Vision $  30.00

Bifocal $  60.00

Trifocal $  80.00

GVS Progressive: $  80.00

Contact Lenses: $110.00

Call:  1-800-VISION if you have any questions.

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