Standard Plan
All eligible employees are entitled to one examination, lenses and cosmetic contacts once every 12
months, frames once every 24 months.
Standard Program Benefits Vision:
Examination
Lenses
Frames
Contact Lenses (Medically Necessary)
Contact Lenses (Cosmetic)
A complete analysis of eyes and related structures.
To correct vision problems-lenses may be plastic or
impact-resistant glass.
The plan offers a wide selection of frames; however, if you
select frames which cost more than the amount allowed by
your plan ($50 wholesale), there will be an additional
charge.
Will be considered for payment by NVA when an NVA
Participating Provider secures prior authorization for the
following conditions: a) Following cataract surgery, b) To
correct extreme visual acuity problems that cannot be
corrected to 20/70 with spectacle lenses, c) Anisometropia,
d) Keratoconus. Usual, Customary & Reasonable.
To correct vision problems, $150 allowance ($30 towards
examination, $120 towards contact lenses).
How the Standard Program Works:
BlueCross Vision has a network of participating Ophthalmologists, Optometrists, and Opticians and retail
optical centers to serve you. Members have direct Single Sign-On (SSO) access from
mycapbluecross.com to their BlueCross Vision coverage information as administered by National
Vision Administrators’ (NVA®).
Through the web site members can:
view eligibility for services
find network providers
view claims status
nominate a provider to join the network
get answers to frequent asked questions
Participating Provider: When making your appointment with a BlueCross Vision Participating Provider,
please notify them that you have BlueCross Vision coverage administered by NVA and sponsored by
Pennsylvania State Employees Credit Union. The provider will verify your vision care eligibility and
benefits
At the time of your appointment simply present your BlueCross Vision identification card. You do not need
to obtain a vision claim form. The provider will inform you of your eligibility status prior to rendering
services. To verify benefit eligibility yourself prior to scheduling your eye care appointment, you may wish
to contact Customer Service at the following toll free number: (800) 905-4102.
When the services have been completed, the Provider will have you sign a claim form and he or she will
then forward the form to NVA for processing and payment.
Non-Participating Provider: If you select a non-participating eye care provider you will be responsible for
one hundred percent (100%) of the cost at the time of service. Remember: obtaining vision care services
from a non-participating provider will result in unnecessary out-of-pocket expense. The following nonparticipating provider direct reimbursement fee schedule has been established
Non-Participating Provider:
Routine Vision Examination
Tonometry
Single Vision Lenses (pair)
Bifocal Lenses (pair)
Trifocal Lenses (pair)
Lenticular Lenses (pair)
Frames
Cosmetic Contact Lenses
Medically Necessary Contacts
up to $37.00 (excluding Contact Lens
Exam)
up to $3.00
up to $40.00
up to $55.00
up to $90.00
up to $120.00
up to $70.00
up to $110.00
Usual, Customary and Reasonable
Reimbursement will be made directly to you from NVA. You must submit a completed Reimbursement
Request Form and a copy of the itemized receipt to the following address:
National Vision Administrators
Attn: Customer Service
P.O. Box 2187
Clifton, NJ 07015
Or Fax to: (973)-574-2495
Attn: Deborah Tyler
When submitting paperwork, you should make copies of everything before sending them to ANY
insurance provider. That way you can follow-up and have back-up with any questions that may arise.
Exclusions Services and materials not covered under the plan. No payment will be made for: medical or
surgical treatment; drugs or medications; non-prescription lenses; examinations or materials not listed as
a covered service; replacement of lost, stolen, broken or damaged lenses; contact lenses or frames
except at normal intervals when service is otherwise available; services or materials provided by Federal,
State, Local Government or Workers' compensation; Examinations, procedures training or materials not
listed; industrial 3 (mm) safety lenses and safety frames with side shields; parts or repair of frames;
sunglasses.
If any item is selected from the exclusion list, you will be required to pay for the full cost of the lenses.
Limitations
The items below can be provided under your plan. However, if you select any of these items, you must
pay the difference between your scheduled plan allowance and the cost of the item selected.
Photochromatic (gray and brown) light or dark, tinted (others than pink #1 or #2), gradient or fashion
colors, progressive or no-line multifocals, a frame costing more than the plan allowance, Coatings: mirror,
anti-reflective, super a.r., color, edge, ultra violet, polish edges, smart segment, scratch resistant (lab or
manufacturer applied), rimless, Polycarbonate, oversize lenses.
Questions or requests for information should be directed to:
Customer Service
(800) 905-4102
Reimbursement Plan
Employees and dependents enrolled in this program are entitled to a reimbursement of eligible vision
expenses up to $200 per year. Eligible vision expenses include exam, frames, lenses, and contact lenses.
Prescription sunglasses are also covered.
Reimbursement
You are required to pay 100% of the expenses and then submit the expense for reimbursement.
Reimbursement will be made directly to you from NVA. You must submit a completed Reimbursement
Request Form and a copy of the itemized receipt to the following address:
National Vision Administrators
Attn: Claims Department
P.O. Box 2187
Clifton, NJ 07015
or fax to: Deborah Tyler at (973) 574-2430
(When submitting paperwork, you should make copies of everything before sending them to ANY
insurance provider. That way you can follow-up and have back-up with any questions that may arise.)
As an enrollee in the Direct Reimbursement Program All you or your eligible dependents have to do is
present your BlueCross Vision Identification card to a participating provider.
A schedule of the discounts is as follows:
Routine Vision
Analysis
Tonometry Test
Clear Lenses (Per
Pair)
Single Vision
Bifocal
Trifocal
$27.00 (excluding
Contact Lens
Analysis)
$3.00
Glass
Plastic
$30.00
$41.00
$50.00
$31.00
$45.00
$55.00
Lens - The BlueCross Vision participating provider will charge you up to the wholesale cost, plus fifty
percent (50%) on each option selected, or their usual, customary and reasonable fee, whichever is less.
Standard Lens Options Include - Photochromatic, Scratch Resistant, Fashion or Gradient Tints,
Progressive or No-line Multifocals, Anti-reflective, Polycarbonate and Prescription Sunglasses.
Frames - The participating provider will charge you up to the wholesale cost for frames, plus fifty percent
(50%), or their usual, customary and reasonable fee, whichever is less. This pricing structure greatly
reduces your out-of-pocket expenses. Eye care providers normal retail prices on frames are often as
much as three times (3X) the wholesale cost.
Contact Lenses - The participating provider will charge his or her usual, customary and reasonable fee,
less twenty-five percent (25%) for contact lenses, including the contact lens examination.
Lenticular Lenses - The participating provider will charge his or her usual fee, less twenty-five percent
(25%).
Exclusions
The following services and materials are not covered under this program: Medical or Surgical Treatments
of the Eyes/Drugs or Medication/Non-Prescription Lenses/Examination or Materials Not Listed as a
Covered Service/Services or Materials Provided By Federal, State, Local Government or Worker's
Compensation/Low Vision Aids.
Vision Providers
A list of participating vision providers can be found at www.capbluecross.com. You can also call Customer
Service at (800) 905-4102
Benefit Services
If you or your vision provider has any questions about claim filing procedures or the status of your claim,
please feel free to contact:
Blue Cross Vision Customer Service @ 1-800-905-4102
Note - This sheet is for informational purposes only. This information sheet will not modify such contract in
any way, nor shall the subscriber accrue any additional rights because of any statement in or omission
from this information sheet.