Vision Summary of Benefits: Administrative

ODS Vision Plan

  Coverage
Plan Maximum $450.00
Routine Eye Exam (once per calendar year) 100%
Lenses (once per calendar year – one pair of lenses or contacts)
  • Single Vision
  • Bifocal
  • Lenticulat
  • Trifocal
100%
Contact Lenses (once per calendar year – contacts or one pair of lenses)
  • Conventional
  • Disposable
 100%
Frames
  • Less than age 17 - once per calendar year
  • 17 and older - once in a two year calendar period
 100%
Limitations: Contracted providers are reimbursed up to their contracted amount. Non-contracted providers are reimbursed up to the maximum plan allowable.

General Exclusions for ODS Vision Plans

  • Orthoptics or vision training
  • Subnormal vision aids and any associated supplemental testing
  • Prisms, prism segs, slab-off, and other special purpose vision aids
  • Replacement of lost, stolen, or broken lenses, except at normal intervals
  • Non-prescription lenses and sunglasses
  • Benefits Not Stated
  • Medical or surgical treatment of the eyes or supporting structures
  • Corrective eyewear required by an employer and safety eyewear unless specifically covered
  • Services or supplies which are payable under a workers’ compensation or occupational disease law
  • Service or supply that is not necessary or does not meet professionally recognized standards
  • Hard and/or scratch resisting coating(s)
  • UV coating
  • Lasik
  • Standard polycarbonate
  • PRK (photo refractive keratectomy)
  • Charges Over the Maximum Plan Allowance
  • Standard anti-reflective

Full Vision Plan Book:   Vision Plan 3



Last updated on April 13, 2009 - 12:30pm