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Vision Coverage Information
The Vision Plan, provided through Spectera, features:
- covered exams and materials;
- statewide access to a network of panel providers;
- no claims to file for "in-network" benefits; and
- benefits for "out-of-network" providers.
Spectera's participating provider network includes private practice optometrists,
ophthalmologists and retail chains (currently most of the Wal-Mart stores in Georgia).
When you make an appointment with a network provider, ensure that they still are
participating in Spectera's network. Then identify yourself as eligible through the State of
Georgia Flexible Benefits Program Spectera Vision Plan and provide your (employee's)
social security number along with the patient's date of birth.
If you receive covered services from a network eye care provider, you will receive the benefits shown in the chart on chart below. You will not be required to file a claim, but will be responsible at the time of service for any co-payments and the cost of any non-covered service or equipment.
If you receive care from an out-of-network provider, you pay the cost at the time of service and submit a receipt to Spectera to be reimbursed for covered out-of-network benefits. Receipts must be submitted together for services and materials purchased on different dates to receive reimbursement. Mail your itemized receipts, with your Social Security number and patient's date of birth to:
Spectera Claims Department
P.O. Box 30978
Salt Lake City, UT 84130
>
IF YOU HAVE ANY QUESTIONS about your vision care plan option, please contact Spectera's customer service at 1-800-638-3120.
Important to Remember
Certain standard contact lenses, including daily wear, and up to 4 boxes of standard single vision disposable contacts are covered in full for your co-payments. If you purchase contacts that are not among Spectera's "covered in full" selection, you will receive an annual $105 allowance toward the purchase of contact lenses, and professional fees (i.e., fit and follow-up). Please note: To receive the full $105 allowance, you must receive your exam, fitting and evaluation at a single visit to the same network provider (at Wal-Mart, $70 of the $105 allowance is allocated to materials and $35 to professional fees). The allowance will only apply to one purchase per plan year. You must submit all receipts at the same time. Any balance remaining and not used during the plan year when the purchase occurred will be forfeited.
Spectera covers standard single vision and standard lined multi focal lenses for glasses. Cosmetic lens options such as tinting, UV coating, progressive lenses, etc., are not covered, but are provided to Spectera's members at a savings below normal retail charges.
Always verify coverage by identifying yourself as a Spectera member under the State of Georgia plan when making your appointment. Give the provider the employee's social security number, patient's name and the patient's date of birth. Benefits are provided every 12 months for exams, lenses and/or contacts and every 24 months for frames measured from the last date of service.
Medically Necessary
A member qualifies for medically necessary contact lenses if Spectera establishes that an eligible member has any of the following:
Keratoconus or irregular astigmatism;
Anisometropia of 3.50 diopters or more;
Post cataract surgery without intraocular lens; or
Visual acuity in the better eye of less than 20/70 with spectacles, but better than 20/70 with contacts.
Exclusions
The Vision Plan does not cover:
replacement of lost lenses or frames
medical or surgical treatment of eye conditions
amounts above the schedule of benefits or allowances
services or materials not included as eligible expenses by the Vision Plan
cosmetic extras such as no line multifocal lenses, tints, UV coatings etc.
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Routine Eye Exam
Every 12 months
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Covered after $10 copay
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Reimburses up to $40
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Contact Lenses
Every 12 months in place of eyeglasses
Medically Necessary**
Not Medically Necessary**
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Covered after $20 materials copay*
Covered after $20 material copay* for covered
lenses selected from Spectera list. Up to four boxes
of covered disposable contact lenses are included
when using a network provider. All other contacts
available through a $105 allowance that includes
fitting, follow-up & materials. Please note
to receive the full $105 credit, you must receive
your exam, fitting evaluation and all contact
materials at the same provider at the same time.
(At Wal-Mart $70 of the $105 allowance is allocated
to materials and $35 to professional fees).
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Reimburses up to $200
Up to $105 max that includes fit, follow-up &
materials |
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• Remember: If you use in-network providers,
you are responsible only for your portion of
cost. If you decide to use a non-network provider,
you pay everything and seek the out-of-network
benefits payments schedule.
* Only a one time $20 material copay applies
per benefit period.
**As defined herein
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