Vision Care charges for one pair of glasses (lenses and frames) or contact lenses, when prescribed by a legally qualified Ophthalmologist or Optometrist, up to the maximum shown in the “SUMMARY OF BENEFITS”.  No amount is payable for replacement of lost or stolen glasses, broken glasses, duplicate glasses, or sunglasses, anti-reflective coatings, or for tints other than No. 1 or No. 2.  Members only may elect to purchase safety glasses in lieu of regular lenses and frames.

Eye examinations for eligible members and dependents who are over age 19 and under age 65, when rendered by a legally qualified Optometrist or Ophthalmologist, up to the limits specified in the “SUMMARY OF BENEFITS’. 

How to File a Vision Care Claim

A properly completed Vision Care claim form is required for each insured family member.   Paid receipt of purchase must be attached.
Each Vision Care claim must show the:

  1. patient's full name
  2. charge for lenses
  3. charge for frames
  4. charge for miscellaneous items


Proof of Loss

Written proof stating the occurrence, character and extent of loss must be submitted for each benefit to the administrator within 15 months after the date of the loss, but not more than 90 days after the date coverage terminates, for Extended Health Care Benefits.


To prevent fraud, it is the member’s responsibility to verify the information contained in each Explanation of Benefits paid, in order to ensure you actually received those services.