Optical Form*
Optical Guidelines

BTF / SBF OPTICAL PLAN

WHO IS COVERED?

UNDER THE PROVISIONS OF THE BTF SUPPLEMENTAL BENEFIT FUND OPTICAL PLAN ALL MEMBERS, THEIR SPOUSES AND ELIGIBLE DEPENDENTS ARE COVERED. DEPENDENTS ARE COVERED UNTIL AGE 23.

WHAT ARE THE BENEFITS?

COVERED VISION SERVICES CONSIST OF THE CARE AND TREATMENT WHEN PERFORMED OR PRESCRIBED BY A PHYSICIAN OR A DULY LICENSED OPTOMETRIST ACTING WITHIN THE SCOPE OF THE LICENSE AND INCLUDES THE FOLLOWING:

  1. A COMPREHENSIVE MEDICAL EXAMINATION RENDERED BY A DULY LICENSED PHYSICIAN OR A COMPLETE VISION SURVEY AND ANALYSIS PERFORMED BY A DULY LICENSED OPTOMETRIST.
    1. TEACHER MEMBERS: $ 35.00 FOR ONE EXAMINATION IN A TWO (2) YEAR PERIOD.
    2. DEPENDENTS: $ 20.00 FOR ONE EXAMINATION IN A TWO (2) YEAR PERIOD

  2. LENSES AND FRAMES:
    YOU ARE NOW ELIGIBLE FOR A FIRST AND SECOND SERVICE ON BOTH FRAMES AND LENSES (WHICH INCLUDES CONTACT LENSES) IN A TWO (2)-YEAR PERIOD. THIS MEANS THAT IF YOU ARE ELIGIBLE FOR A FIRST SERVICE AND PURCHASE JUST FRAMES, YOU ARE STILL ELIGIBLE FOR A FIRST SERVICE ON LENSES (OR VICE VERSA). A TWO YEAR PERIOD BEGINS ON THE DATE OF YOUR FIRST SERVICE (WHICH IS THE DATE YOU ORDER YOUR GLASSES) AND ENDS PRECISELY TWO YEARS LATER. THE NEXT TWO-YEAR PERIOD BEGINS WHEN YOU APPLY FOR BENEFITS AFTER THE PREVIOUS TWO-YEAR PERIOD HAS EXPIRED. IF YOU HAVE ANY DOUBTS CONCERNING YOUR ELIGIBILITY CALL BEFORE YOU PURCHASE YOUR GLASSES.

PLEASE SEE THE LISTING OF THE RATES IN EFFECT AS OF JULY 1, 2000

  1. REIMBURSEMENT WILL NOT BE PAID FOR THE FOLLOWING:
    1. SERVICES RENDERED AFTER THE DATE THE INDIVIDUAL CEASES TO BE COVERED HEREUNDER.
    2. REIMBURSEMENTS REQUESTED AFTER 6 MONTHS OF THE DATE THE SERVICE WAS PERFORMED.
    3. CARE OR TREATMENT RENDERED, FINISHED OR STARTED, PRIOR TO THE EFFECTIVE DATE OF YOURCOVERAGE.

WHAT IS THE REIMBURSEMENT PROCESS?

YOU ARE RESPONSIBLE FOR 100 % PAYMENT TO THE OPTICIAN. AFTER FULL PAYMENT HAS BEEN MADE TO THE OPTICIAN, MAIL THE COMPLETED CLAIM FORM TO THE SBF OFFICE FOR REIMBURSEMENT. CLAIMS SUBMITTED FOR REIMBURSEMENT MUST BE MADE WITHIN SIX (6) MONTHS OF THE DATE OF SERVICE.

 

BTF / SBF OPTICAL PLAN PAYMENT SCHEDULE

REIMBURSEMENT RATES FOR TEACHER MEMBER:

  1ST SERVICE 2ND SERVICE
FRAMES $ 40.00 $ 30.00
LENSES - PER PAIR (RATES ALSO APPLY TO PRESCRIPTION SUNGLASSES)
SINGLE VISION $ 40.00 $ 30.00
BIFOCAL $ 45.00 $ 30.00
TRIFOCAL OR EZ 2 VUE $ 65.00 $ 45.00
PROGRESSIVES $ 75.00 $ 50.00
HIGH INDEX(OVER 4.00 DIOPTERS) $ 45.00 $ 30.00
PRISM LENSES $ 5.00 $ 5.00
CONTACT LENSES $ 85.00 $ 50.00
UV 400 ULTRAVIOLET RAYS REMOVED FOR COMPUTER USE $ 15.00 $ 12.00
ANTI-REFLECTIVE COATING $ 20.00 $ 15.00
     
EXAMINATION:    

MEMBER

 $ 35.00  

DEPENDENTS

 $ 20.00  

 

REIMBURSEMENT RATES FOR SPOUSE AND DEPENDENTS :

REIMBURSEMENT RATES FOR SPOUSE AND DEPENDENTS ARE IDENTICAL TO THE RATES FOR TEACHER MEMBERS LISTED UNDER THE 2ND SERVICE COLUMN ABOVE. SPOUSES AND DEPENDENTS ARE ALSO ENTITLED TO TWO SERVICES ON FRAMES AND LENSES PER TWO YEAR PERIOD.

PAID RECEIPTS MUST ACCOMPANY ALL CLAIM FORMS !!!

THESE RATES ARE EFFECTIVE FOR SERVICES PERFORMED / ORDERED ON OR AFTER JULY 1, 2000.

EFFECTIVE 7/1/00

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