OPTICAL CARE

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AMERICAN FEDERATION OF STATE, COUNTY & MUNICIPAL EMPLOYEES / AFL-CIO

VISION CARE BENEFIT

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The standard optical benefit is available to the member and his/her eligible dependents once every two years, measured exactly two years from the last day of service. The benefit consists of an eye examination, lenses and frames.

There are three ways of using the optical benefit: using the voucher, getting direct reimbursement or using the DC 37 Vision Center at 115 Chambers Street in Manhattan.

Using a Voucher

If the member wishes to use this method, he/she must complete a Voucher Request Form and send it to the Plan office, or call the Plan office at 212-815-1234 and request a Voucher. Upon receipt of the request, a voucher together with a listing of participating opticians will be forwarded to the member's home. The voucher can be taken to any of our participating providers and the glasses will be provided free of charge. If other than the Plan's frames and lenses are selected, the member will be responsible for the additional expense.

Using Direct Reimbursement

If this method is chosen, the member must complete an Optical Reimbursement Form and submit it to the Plan office for processing. Payment will be calculated according to the Plan's optical reimbursement fee schedule (see Full-Time Benefit Booklet for schedule allowances).

In order to maximize the optical benefit, the member must obtain and file for all three services - eye examination, lenses and frames - simultaneously on the same claim form, whether using the voucher or direct reimbursement method. Remember, the three parts of the benefit cannot be split between the two available methods - voucher or direct reimbursement (except in New Jersey and Florida). The member should also be aware that partial usage of the benefit will be considered the same as full usage.

Using the Vision Center

Appointments must be scheduled in advance at the DC 37 Vision Center, call (212) 766-4452. The Center accepts calls for appointments beginning the last Monday of each month (10-3 daily) until all available appointments are filled.

If a member or eligible dependent plans to use the DC 37 Vision Center, he/she does not have to request a voucher, one will be requested by the Center after an appointment has been scheduled. If the member or eligible dependent plans to use the standard benefit with an outside prescription, no appointment is necessary, however, the patient must request a voucher from the Plan office and bring both the prescription and voucher to the dispensary.

Supplemental Optical Benefit

In addition to the standard optical benefit, the member and his/her eligible dependents can apply for the Supplemental Optical Benefit. This benefit is provided at the Vision Center only and is available once every 12 months measured from the date the standard benefit was last used. The benefit includes an eye examination and a change of lenses, if prescribed by the Vision Center's Optometrist.

Reminder

1. If the member should need glasses for any reason, e.g. an additional pair is desired or the glasses were lost or destroyed before the eligibility waiting period is satisfied, the member should be aware that frames and lenses can be obtained (member must provide the prescription) at the Center and at a Participating Provider at a moderate cost without an appointment.

2. All information submitted should indicate member's name and social security number - even when requesting benefits/services for spouse/children.

3. A voucher is used for exam, frames and lenses (single and bifocal). For cataracts and contact lenses, the reimbursement method should be used.

4. If the voucher has been lost, destroyed, or never received, the member should call the Plan office and request a notary letter. Once the notary letter is completed by the member and returned to the Plan office, a new voucher will be issued.

5. If the voucher is outdated, the voucher MUST be returned to the Plan office indicating if the voucher is to be voided only, or voided and reissued.

DC 37 OPTICAL FEE SCHEDULE

Optical Fee Schedule effective November 8, 2002.

DESCRIPTION FEE

Eye Examination .............................................................$6

Single Vision Lenses (Standard lenses) ..............…..$9

Bifocal Lenses (Standard lenses) ...............................$16

Trifocal Lenses (Standard lenses) ..............................$20

Progressive Lenses (Standard lenses) ................…..$16

Frame ...........................................................................…..$5

Plastic Aspheric Single Vision Cataract Lenses …..$40

Plastic Aspheric Bifocal Cataract Lenses .................$65

Contact Lenses ...............................................................$14

Cataract Contact Lenses*..............................................$45

*If you are Medicare eligible, you must use Medicare as the primary (first) carrier when you submit a claim for cataract lenses. In addition, if you use the Vision Center for this service, a claim must be completed and submitted for processing to Medicare.

LIST OF OPTICAL PROVIDERS

(ACROBAT READER REQUIRED)

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