Vision Insurance

See yourself healthy

Offering low or no out-of-pocket costs for eye exams, eyeglasses and contact lenses when services are rendered by a participating provider. If using a non-participating provider or supplier, reimbursement up to the plan allowance. Claim forms required.

Benefits available once yearly from date of last service/treatment.

PLEASE NOTE: Benefits for this plan are based on a service date basis.

Make a Payment Brochure Application / Change Form Vision Rate Letter Find a Provider Member Guide Member Portal Claim Form - Out of Network Provider

Discount Features

Non-Covered Eyewear Discount: Members may also receive a discount of 20% from a participating provider’s usual and customary fees for eyewear purchases which exceed the benefit coverage (except disposable contact lenses, for which no discount applies). This includes eyeglass frames which exceed the selected benefit coverage, specialty lenses (i.e. progressives) and lens “extras” such as tints and coatings. Eyewear purchased from a Walmart Vision Center does not qualify for this additional discount because of Walmart’s “Always Low Prices” policy.

Benefits

In-Network Out-of-Network
Exam Covered in full Up to $35 retail
Frames $125 retail allowance Up to $80 retail
Contact Lenses2 $150 retail allowance Up to $90 retail
Medically Necessary Contact Lenses Covered in full Up to $150 retail
Laser Vision Correction $200 retail allowance3
Lenses (standard) per pair
Single Vision Covered in full Up to $25 retail
Bifocal Covered in full Up to $40 retail
Trifocal Covered in full Up to $45 retail
Progressive See description1 Up to $45 retail
Lenticular Covered in full Up to $80 retail

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements
1Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay
2 Contact lenses and related professional services (fitting, evaluation and follow-up) are covered in lieu of eyeglass lenses and frames benefit
3Lasik Vision Correction is in lieu of eyewear benefit, subject to routine regulatory filings and certain exclusions and limitations

Return completed forms to Gallagher Affinity at:

Gallagher Affinity
P.O. Box 4111
Clinton, IA 52733
Fax: 215-351-9012
Email: Irene_Walton@ajg.com
Questions: 800-952-4050 ext. 4765