Vision
| The vision care benefit is provided for all active participants and their dependents. (Coverage for self-pay participants may be different.)
To use the Plan's vision care benefit, obtain a Medical Eye Services claim form and a listing of participating providers from the Administrative Office. Take the claim form with you to your chosen eye care provider; either you or the provider will need to submit the form for payment or reimbursement. |
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Vision Exam | Every 12 months | No charge | $40 allowance |
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Lenses | Every 24 months OR at a 12-month interval if the prescription change so indicates | No charge for standard lenses | Allowance varies based on lens type |
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Frames | Every 24 months | No charge for standard frame | $40 allowance |
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Contact Lenses | Every 24 months OR at 12-month intervals and if the prescription change so indicates (this benefit is in lieu of lenses and frame) | Cosmetic or convenience: up to $150
Medically necessary: Covered in full | Cosmetic or convenience: up to $150
Medically necessary: up to $250 |
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Hearing Care Benefit
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Overview | The Plan pays for audiology on the same basis as any other specialist physician visits. For audiology, Sacramento ENT (Ear, Nose and Throat) is the sole preferred provider.
Sacramento ENT Medical Group is located at:
3810 “J” Street
Sacramento, CA 95816
(916) 736-3399
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| In-Network | Out-of-Network1 | |
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Audiologists | 90% of contract rate at Sacramento ENT, after deductible | 70% of usual, customary & reasonable, after deductible |
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Hearing Aids | 90% of contract amount, when provided through Sacramento ENT, after deductible | 70% if Pre-Certified by Sacramento ENT, after deductible. Not covered unless Pre-Certified by Sacramento ENT.2 |
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| $4,000 ($2,000 per ear) maximum payment.
Adults (18 & over): one aid per ear every 3 years, if necessary.
Children (under the age of 18): one aid per ear every calendar year, if necessary.
Annual hearing aid maintenance check is required; otherwise, the Plan will not pay for replacement of hearing aids. |
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Annual Maintenance Check | 90% of contract rate, after deductible, up to $30 | 70% of usual, customary and reasonable, after deductible, up to $30 |
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1 Only In-Network benefits count toward the $5,000 coinsurance maximum. Charges incurred Out-of-Network will never be paid at 100%.
2 If you use an audiologist other than Sacramento Ear, Nose and Throat your audiology report must be sent to Sacramento Ear, Nose and Throat so the hearing aids can be pre-Certified for coverage.
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