14-Exhibit K Vision Benefits.pdf
PDF 128 KB Posted
- Attached to
- District Wide Employee Benefit Services.
- Solicitation number
- RFP 099-2026
- Issued by
- St. Louis County, Missouri
About this file
Vision Benefits Plan Exhibit
This document is a vision benefits plan exhibit for the Board of Education of the City of St. Louis under VBA #670, effective January 1, 2024 through December 31, 2026. The plan provides comprehensive vision coverage for employees, spouses, and dependent children up to age 26, including vision examinations, corrective lenses, frames, and contact lenses through a network of participating providers such as Costco Optical, Pearle Vision, LensCrafters, Target Optical, Eyeglass World, America's Best, and Boscov's Optical. Vision exams and materials are available at specified frequencies, with employees eligible for exam and material services every 12 and 24 months respectively. The plan structure allows members to select either in-network benefits with applicable copayments or out-of-network reimbursement with no copay requirements.
The plan incorporates a $10 copayment for vision exams and a $10 copayment for total lens and frame costs at VBA participating providers. In-network benefits cover standard lenses in full following copayment, with frame allowances up to $40 at participating locations and contact lens material allowances up to $105 for elective contacts or $210 for medically necessary contacts requiring prior approval. Out-of-network maximum reimbursement rates range from $28 to $80 depending on lens type, with a $45 frame allowance. The plan excludes coverage for cosmetic enhancements such as tinted, photochromic, polarized, or hi-index lenses; non-prescription lenses; and services related to worker's compensation or employer-mandated eye examinations. Members are responsible for costs exceeding plan allowances and may incur out-of-pocket charges for optional enhancements and premium frame selections.
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Board of Education City of St Louis VBA #670
Effective: 1/1/2024-12/31/2026 $10 Exam / $10 Materials Copay
Dependent Age: 26 (EOBM) Frequency Type:
Last Date of Service
Employee Spouse Children
Vision Exam 12 Months 12 Months 12 Months Lenses 24 Months 24 Months 24 Months Frames 24 Months 24 Months 24 Months
Benefits:
Employee Can Select Either
VBA Participating Provider Amount Covered/Benefit (After Applicable Copay)*
Out-of-Network
Max Reimbursement (Zero Copay)
Vision Exam (Glasses) Covered in Full $36 Retinal Screening with Exam Copay not to exceed $39 N/A Clear Standard Lenses (Pair):
Single Vision Covered in Full $28 Bifocal Covered in Full $45 Blended Bifocal Covered in Full $45 Trifocal Covered in Full $56 Progressives Partially-Covered $56 Lenticular Covered in Full $80 Polycarbonate Covered in Full for
Persons Up to Age 19 N/A
Basic Scratch Coating Covered in Full N/A Frame (Wholesale Allowance) Up to $40 $45
-OR-
Elective Contacts (in lieu of eyeglass benefits) Material Allowance Up to $105A $105
-OR-
Medically Necessary Contacts Covered in FullB $210
Where an “allowance” is shown above, the Member is responsible for paying any charges in excess of the allowance less any applicable copay.
Benefits and participation may vary by location, including, but not limited to, Costco® Optical, Pearle Vision, LensCrafters®, Target Optical®, Eyeglass World®, America’s Best® and Boscov’s™ Optical.
A The allowance is applied to all services/materials associated with contact lenses, including, but not limited to, contact fitting, dispensing, cost of the lenses, etc.
No guarantee the allowance will cover the entire cost of services and materials.
B Requires prior approval. May only be selected in lieu of all other material benefits listed herein.
* A $10 copayment is applied to the vision exam and a $10 copayment is applied to the total cost of the lenses and/or frames ordered from a VBA Member Doctor only. Copayments do not apply to the contact materials.
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Board of Education City of St Louis VBA #670
This plan is designed to cover your visual needs rather than cosmetic options.
Additional Charges You may incur out-of-pocket charges when selecting any of the following:
• Tinted Lenses
• Photochromic/Polarized Lenses
• Polycarbonate (covered under age 19)
• Hi-index Lenses
• Progressive (available starting at $29)
• The coating of the lens or lenses (except Basic Scratch Coating)
• A frame that costs more than the plan allowance
• Rimless Frames
• Anti-Reflective
Additionally, costs for contact lenses/services in excess of the plan’s scheduled reimbursement allowances are the responsibility of the patient.
Not Covered The contract gives VBA the right to waive any of the plan limitations if, in the opinion of our optometric consultants, it is necessary for the patient’s welfare. VBA provides no benefit for professional services or materials connected with the following:
• Orthoptics or vision training
• Non-prescription lenses
• Two pair of glasses in lieu of bifocals
• Medical or surgical treatment of the eyes
• An eye examination, or corrective eyewear, required by an employer as a condition of employment
• Services of materials provided as result of any Worker’s Compensation Law or similar legislation
• Glasses and contacts during the same eligibility period
Lenses and frames furnished under this program which are lost or broken will not be replaced except at the normal intervals when services are otherwise available.
Additional Terms and Conditions Frame allowance is based on wholesale pricing at non-retail locations. Frame allowance, contact lens pricing and policies vary by location. Contact your provider before requesting services.
Benefits may only be used for contact lenses when selected in lieu of all other materials and services. If purchased at the same time from a single provider, you will receive a total allowance of up to $105 towards the cost of a routine eye exam, contact fitting fees and contact lenses. Any provider charges that exceed this amount shall be the responsibility of the member. Members may be required to pay contact fitting fees out of pocket at some locations.
Benefits and participation may vary by location and where prohibited by state law.
Exam copay is not required if benefits are used to purchase contact lenses from a single provider on the same day of the member's exam. Material copays do not apply to contact lenses.
Benefits may only be used for medically necessary contact lenses when selected in lieu of all other materials.
Additional terms and conditions apply. Contact VBA at 412-881-4900 for more information.
| Additional Charges |
| Not Covered |
| Additional Terms and Conditions |
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