5/20/2024
SECTION G
VISION CARE BENEFITS
Section Page
Eligibility ......................................................................................................................................................... G . 1
Benet Year ................................................................................................................................................... G . 1
Benet Options ............................................................................................................................................. G . 1
Schedule of Benets ...................................................................................................................................... G . 1
Charges Not Covered .................................................................................................................................... G . 2
Specic Details of Your Vision Care Benet Options ..................................................................................... G . 2
Contact Lens Mail-Order Program ................................................................................................................. G . 4
Laser Vision Correction Services ................................................................................................................... G . 4
COBRA Optional Coverage ........................................................................................................................... G . 4
Claims Administrator ...................................................................................................................................... G . 5
G. VISION CARE BENEFITS
ELIGIBILITY
Members and their dependents are eligible for Vision Care Benets as long as they satisfy the eligibility and
enrollment requirements as outlined in the “Fund Eligibility and Membership” section of this booklet.
BENEFIT YEAR
The Vision Care Benet year runs from January 1st through December 31st.
BENEFIT OPTIONS
There are two options for obtaining vision care benets through the Vision administrator, General Vision Services (GVS):
• In-Network (PPO) Benet: You utilize one of the Fund’s in-network participating vision care providers for full-service
benets, paid in full directly by the Fund to the provider and without incurring any out-of-pocket expense on your part
for most services.
• Out-of-Network Option: You select and directly pay the provider of your choice, le a claim with the Fund’s Vision
Care Administrator, and you are reimbursed up to the scheduled limits. The maximum benet is $150 per covered
person, per benet year. In order to be considered for payment, all claims must be submitted within 24 months from
the date of services. Claim form can be requested by e-mailing the vision care provider directly at mbfmembers@
gvsbenets.com
Once selected, only one of the above options (In-Network or Out-of-Network) may be used for all services within a benet
year. (In-network/out-of-network benets do not need to be obtained during a single visit.)
Important: Please refer to the section on “Specic Details of Your Vision Care Benet Options” (see page G.2) for com-
plete information on the in-network (PPO) and out-of-network options.
SCHEDULE OF BENEFITS
Covered Charges
Covered charges are the usual and customary charges for the services and supplies recommended and made by a
legally qualied ophthalmologist(s), optometrist(s), or optician(s) during the benet year. Covered charges include:
• Lenses (including contact lenses and prescription sunglasses): One pair of glass or plastic spectacle lenses is cov-
ered each benet year, per covered individual. However, if there is a prescription change or accidental breakage
during the benet year, the spectacle lenses (not contact lenses) may be replaced (under the out-of-network option
only) with reimbursement limited to the unused portion of the current benet year maximum payment. There is a
one year breakage warranty for collection (plan) frames at in-network locations. In lieu of eyeglasses and at select
GVS locations, convention or disposable (2 week) contact lenses will be oered as plan contacts. An allowance will
be oered for contact lenses deemed non-plan (outside the plan contact lenses) at all GVS (in-network) locations.
• Frames: One pair of eligible frames is covered per person, per benet year. At locations where there is a GVS Frame
Collection, any collection frame up to a retail value of $300 is included at no charge. For members choosing a frame
from the provider’s own selection of frames, a $200 credit will be applied. If you choose to utilize your benet at a
Costco Optical location, please note that the frame allowance will be $80.
Note: You will not be covered for frames in the same benet year for which coverage for contact lenses has been pro-
vided by the Vision Care Plan.
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CHARGES NOT COVERED
The following charges are not covered under the Vision Care Program:
• Services or supplies that are not provided by a licensed and qualied ophthalmologist, optometrist or optician.
• Sunglasses or other spectacle lenses that do not require a prescription.
• Expenses incurred due to an injury or sickness connected with any employment, or for services which are compen-
sated under Workers’ Compensation or similar legislation.
• Repair or replacement of damaged frames or spectacle lenses except under the PPO Option’s warranty provisions
or under the accidental breakage allowance of the out-of-network option. (See “Schedule of Benets,” page G1.)
• Replacement of lost lenses or frames, or replacement of scratched lenses not covered by the in-network plans war-
ranty provisions.
• Services or supplies for which the covered person incurred no expense.
• For frames in the same benet year for which coverage for contact lenses has been provided by the Vision Care
Plan.
• Medical treatment of eye disease or injury.
• Vision therapy.
• Lasik Surgery (However, discounts are available, see Laser Vision Correction Services section).
• Non-prescription (plano) lenses.
SPECIFIC DETAILS OF YOUR VISION CARE BENEFIT OPTIONS
Out-of-Network Option
The Out-of-Network Option reimburses eligible members and dependents up to $150 per person per benet year. Up to
$25 can be submitted for the examination and up to $125 for materials (eyeglasses or contact lenses).
Members receive reimbursement under the Out-of-Network Option as follows:
• Select any qualied provider and pay the provider directly for services rendered.
• The provider and the member should complete the appropriate sections of the Vision Care Direct Reimbursement
Claim Form (located on the MBF website at nyc.gov/mbf), which should then be mailed to:
General Vision Services
520 Eighth Avenue
9th Floor – Attention Out-of-Network Department
New York, NY 10018
• Out-of-Network forms can also be requested from GVS and then e-mailed to: Mbfmembers@gvsbenets.com
• Members are then reimbursed via regular mail by GVS for vision care expenses according to plan guidelines.
• Members may only submit one claim for each covered person during a single benet year to receive the maximum
out-of-network reimbursement amount.
• In order to be considered for payment, claims must be submitted within 24 months of the date of services.
In-Network Option
The In-network option is designed to provide eligible members and dependents with comprehensive services while maxi-
mizing value through reduction or elimination of out-of-pocket expenses. Listed below are key features of this option:
• Annual benet for an eye examination, lenses, and frames.
• No annual deductible.
• For a full listing of in-network PPO providers, please visit www.generalvision.com or call the MBF concierge line at
GVS at 888-906-0393. When searching on the GVS app or the website, please use the MBF group number #6054.
Paid-In-Full Benets:
- Eye Exam
- One eye examination, including a Dilated Fundus Evaluation when professionally indicated, is covered in full
when done by an in-network PPO provider.
- Lenses
- Lenses available through the in-network (PPO) Option at no out-of-pocket member cost include:
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• All prescription ranges in glass or plastic lenses, including prescription sunglasses
• Polycarbonate lenses
• Single vision, bifocal, trifocal and cataract lenses
• Blended Bifocals
• Progressive addition (no-line) multifocals
• Oversized lenses (larger than standard size) for larger frame styles
• Fashion and gradient tints (available for plastic lenses only)
• Photosensitive (plastic) transitions (lenses that darken when exposed to the ultraviolet rays of the sun)
• High-Index lenses (thinner and lighter lenses)
• Polarized lenses
• UV coating
• Reection-free standard coating - Anti-Reective Coating (ARC)*
• Scratch-resistant coating
• Premium ARC is available with the $13.00 copayment
• Ultra ARC is available with a $25.00 copayment
• Ultra Progressive Lenses are available with a $50.00 copayment
• Blue Light Filtering Coating is available at a $25.00 copayment
- Frames
- GVS oers a selection of approximately 200 frames of both metal and plastic construction. This collection in-
cludes selected designer frames from GVS exclusive Frame Collection. Any frame up to a retail value of $300
is included at no additional cost.
- No co-payment is required, and
- Unconditional one-year warranty against breakage is provided.
In Lieu of Eye Glasses (Annual In-network Option, Member May Only Choose One):
- Contact Lenses
Fund members and eligible dependents can obtain specied plan disposable or frequent replacement contact lenses
at no cost. For members prescribed Plan Collection Lenses, up to a 12-month supply is included at no additional cost.
- Non-Plan Contact Lenses or Frames
Under the in-network PPO benet, the Fund provides a specic allowance ($200) for non-plan frames (i.e. special de-
signer frames) or specialty contact lenses. After this designated allowance is applied, the member is responsible for the
dierence and will be responsible for any additional cost, paid directly to the participating provider, without reimbursement
from the Fund. In the case of non-plan contact lenses, the Fund provides the same allowance (in lieu of eyeglasses)
towards purchase. The evaluation, tting, and follow-up cost has been xed at a $50.00 co-payment, OR
- Medically Necessary Contact Lenses
Medically necessary contact lenses are prescribed when a patient’s vision cannot be corrected by either eyeglasses or
standard contact lenses. The following conditions would need to be diagnosed by either an in-network or out of network
provider:
- Keratoconus
- Irregular astigmatism
- High ametropia
- Anisometropia
- Aphakia
- Aniridia
- Thygeson Keratitis
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Once the condition has been diagnosed, the members would need to complete the following steps for approval to assist
with the cost of the lenses:
• Member must contact GVS at the MBF Concierge line at 888-906-0393 or via e-mail to mbfmembers@gvsbenets.
com to request a medical necessary contact lenses approval form.
• Member must bring the form with them to the provider’s oce (for either in-network or out-of-network).
• Provider must complete the form indicating the reason for the need of medically necessary contact lenses.
• Provider must send the form to mbfmembers@gvsbenets.com for review and approval.
• Approval will be completed by GVS within 2 business days and GVS will provide the provider with the approval
needed to proceed.
• Member will pay for the medically necessary lenses at the time of service and then must send the bill to GVS via
e-mail to mbfmembers@gvsbenets.com and will be reimbursed up to $1,500.
Benets and participation may vary by retailer location. Costco locations will provide a wholesale equivalent of $80 for
frame selections.
Procedure for Obtaining in-network Vision Care Services:
The Fund uses a “paperless” voucher system; no paper claim forms or vouchers are needed when utilizing vision
care services from a Fund in-network PPO provider. Just follow these steps to obtain your benets:
1. Select a provider from the Fund’s Vision Care In-Network PPO Directory, which is available by visiting the GVS App,
www.generalvision.com, or by calling GVS directly on the MBF concierge line at 888-906-0393.
2. Make an appointment with the in-network PPO provider of your choice and identify yourself as a Management Ben-
ets Fund member. (Verication of Fund and benet usage eligibility will be conducted directly between the provider
you have selected and GVS.) For members using one of the National Retailers, please identify yourself as a VBA
member having the GVS/MBF benet. Please have your virtual ID card available as you will be asked for your ID
and plan number when visiting the location. You will be asked to provide the last 4 digits of your Social Security
Number for verication.
3. Go to your scheduled appointment, receive your examination, and select your eyewear.
4. Pick up your eyewear when it is ready and sign a Member Record Form verifying your receipt of services and sup-
plies. You do not have to pay the provider unless you selected services or materials that are not covered by the
plan or require a co-payment.
Note: All covered services (eye examination and eyewear) provided by an in-network provider must be scheduled as a
single visit. The Fund will not, for example, pay for an eye examination on July 1, and eyeglasses on October 1 of the
same benet year under the PPO Option.
CONTACT LENS MAIL-ORDER PROGRAM (FOR REPLACEMENT CONTACTS ONLY AFTER THE BENEFIT
HAS BEEN USED)
All members of the Fund and their eligible dependents are eligible to participate in a mail-order contact lens program,
which oers savings on all contact lenses and solutions. Replacement contacts (after initial benet) through 1-800-Any-
Lens mail-order service ensures easy, convenient, purchasing online and quick, direct shipping to your door. They can
be reached directly at 1-800-ANY-LENS or visit www.1800anylens.com
LASER VISION CORRECTION SERVICES
GVS provides you and your eligible dependents with the opportunity to receive Laser Vision Correction Services at dis-
counts. All Lasik Benets are administered by QualSight. Members with questions or who are looking for a participating
provider should call 1-888-568-0308 and identify themselves as a General Vision Services (GVS) member.
COBRA OPTIONAL COVERAGE
If coverage of a member or his/her dependent ends, that person has the right to continue coverage under the federal
law known as the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). Notice of each person’s rights
under this option will be provided by the member’s employing agency. Any person who has questions on COBRA optional
continuance should contact his/her Agency personnel ocer or the Fund Oce.
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CLAIMS ADMINISTRATOR
The Claims Administrator for the Fund’s Vision Care Program is: General Vision Services, 520 Eighth Avenue, 9th Floor,
New York, NY 10018.
Please note that the Management Benets Fund does not endorse or guarantee any of the vision care services covered
by the Vision Care Program and does not endorse or guarantee any of the providers oering those services. You should
exercise independent judgment in screening and selecting an appropriate service provider. Your decision to receive
services and your selection of a particular provider are solely your responsibility.
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