Blue Cross Blue Shield FEP Vision

Blue Cross Blue Shield FEP Vision®

www.bcbsfepvision.com

1-888-550-BLUE (2583)

2024

A PPO Vision Plan, available nationwide and overseas

IMPORTANT

• Rates: Back Cover

• Summary of Benefits: Page 29

Enrollment Options for this Plan:

•High Option – Self Only

•High Option – Self Plus One

•High Option – Self and Family

•Standard Option – Self Only

•Standard Option – Self Plus One

•Standard Option – Self and Family

Introduction

On December 23, 2004, President George W. Bush signed the Federal Employee Dental and Vision Benefits Enhancement

Act of 2004 (Public Law 108-496). The law directed the Office of Personnel Management (OPM) to establish supplemental

dental and vision benefit programs to be made available to Federal employees, annuitants, and their eligible family members.

In response to the legislation, OPM established the Federal Employees Dental and Vision Insurance Program (FEDVIP).

OPM has contracted with dental and vision insurers to offer an array of choices to Federal employees and annuitants. Section

715 of the National Defense Authorization Act for Fiscal Year 2017 (FY 2017 NDAA), Public Law 114-38, expanded

FEDVIP eligibility to certain TRICARE-eligible individuals.

This brochure describes the benefits of Blue Cross Blue Shield FEP Vision under the Blue Cross and Blue Shield

Association’s contract OPM02-FEDVIP-02AP-04 with OPM, as authorized by the FEDVIP law. The address for our

administrative office is:

Blue Cross Blue Shield FEP Vision

711 Troy Schenectady Road, Suite 301

Latham, New York 12110

1-888-550-BLUE (2583)

TTY: 1-800-523-2847

www.bcbsfepvision.com

This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations

and exclusions of this brochure. It is your responsibility to be informed about your benefits. You, and your family members,

do not have a right to benefits that were available before January 1, 2024 unless those benefits are also shown in this

brochure.

If you are enrolled in this plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus

One, you and your designated eligible family member are entitled to these benefits. If you are enrolled in Self and Family

coverage, each of your eligible family members is also entitled to these benefits.

OPM negotiates benefits and rates with each carrier annually. Rates are shown at the end of this brochure.

BCBS FEP Vision is responsible for the selection of in-network providers in your area. Contact us at 1-888-550-BLUE

(2583) or TTY: 1-800-523-2847 for the names of participating providers or to request a provider directory. You may also

request or view the most current directory via our website at www.bcbsfepvision.com. Continued participation of any

specific provider cannot be guaranteed. Thus, you should choose your plan based on the benefits provided and not on a

specific provider's participation. When you phone for an appointment, please remember to verify that the provider is

currently in-network. If your provider is not currently participating in the provider network, you can nominate them to join.

Nomination forms are available on our website, or call us and we will take your nomination over the phone. You cannot

change plans, outside of Open Season, because of changes to the provider network.

Provider networks may be more extensive in some areas than others. Please be aware that the BCBS FEP Vision network

is different from the network of your health plan.

This BCBS FEP Vision plan and all other FEDVIP plans are not a part of the Federal Employees Health Benefits

(FEHB) Program.

We want you to know that protecting the confidentiality of your individually identifiable health information is of the utmost

importance to us. To review full details about our privacy practices, our legal duties, and your rights, please visit our

website, www.bcbsfepvision.com and then click on the “Privacy, Legal, link at the bottom of the page. If you do not have

access to the internet or would like further information, please contact us by calling 1-888-550-BLUE (2583) or TTY:

1-800-523-2847.

Discrimination is Against the Law

BCBS FEP Vision complies with all applicable Federal civil rights laws, to include both Title VII of the Civil Rights Act of

1964 and Section 1557 of the Affordable Care Act. Pursuant to Section 1557, BCBS FEP Vision does not discriminate,

exclude people, or treat them differently on the basis of race, color, national origin, age, disability, or sex.

1 2024 Blue Cross Blue Shield FEP Vision®

Table of Contents

Introduction ...................................................................................................................................................................................1

Table of Contents ..........................................................................................................................................................................2

FEDVIP Program Highlights ........................................................................................................................................................4

A Choice of Plans and Options ...........................................................................................................................................4

Enroll Through BENEFEDS ...............................................................................................................................................4

Dual Enrollment ..................................................................................................................................................................4

Coverage Effective Date .....................................................................................................................................................4

Pre-Tax Salary Deduction for Employees ...........................................................................................................................4

Annual Enrollment Opportunity .........................................................................................................................................4

Continued Group Coverage After Retirement ....................................................................................................................4

2024 Program Highlights ..............................................................................................................................................................5

Section 1 Eligibility ......................................................................................................................................................................6

Federal Employees ..............................................................................................................................................................6

Temporary/Seasonal Employees .........................................................................................................................................6

Federal Annuitants ..............................................................................................................................................................6

Survivor Annuitants ............................................................................................................................................................6

Compensationers .................................................................................................................................................................6

TRICARE-eligible individual .............................................................................................................................................6

Family Members .................................................................................................................................................................7

Not Eligible .........................................................................................................................................................................7

Section 2 Enrollment .....................................................................................................................................................................8

Enroll Through BENEFEDS ...............................................................................................................................................8

Enrollment Types ................................................................................................................................................................8

Dual Enrollment ..................................................................................................................................................................8

Opportunities to Enroll or Change Enrollment ...................................................................................................................8

When Coverage Stops .......................................................................................................................................................12

Continuation of Coverage .................................................................................................................................................12

FSAFEDS/High Deductible Health Plans and FEDVIP ...................................................................................................12

Section 3 How You Obtain Care .................................................................................................................................................13

Identification Cards/Enrollment Confirmation .................................................................................................................13

Plan Providers ...................................................................................................................................................................13

In-Network ........................................................................................................................................................................13

Out-of-Network .................................................................................................................................................................13

Pre-Authorization ..............................................................................................................................................................13

FEHB First Payor ..............................................................................................................................................................14

Coordination of Benefits ...................................................................................................................................................14

Limited Access Areas ........................................................................................................................................................14

Section 4 Your Cost for Covered Services ..................................................................................................................................15

Copayment ........................................................................................................................................................................15

In-Network Services .........................................................................................................................................................15

Out-of-Network Services ..................................................................................................................................................15

Section 5 Vision Services and Supplies ......................................................................................................................................16

Diagnostic .........................................................................................................................................................................16

Eyewear .............................................................................................................................................................................16

Contact Lenses ..................................................................................................................................................................18

Section 6 International Services and Supplies ............................................................................................................................22

2 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

International Claims Payment ...........................................................................................................................................22

Finding an International Provider .....................................................................................................................................22

Filing International Claims ...............................................................................................................................................22

Customer Service Website and Phone Numbers ...............................................................................................................22

International Plan Allowances ..........................................................................................................................................22

Section 7 General Exclusions – Things We Do Not Cover .........................................................................................................24

Section 8 Claims Filing and Disputed Claims Processes ............................................................................................................25

How to File a Claim for Covered Services .......................................................................................................................25

Deadline for Filing Your Claim .........................................................................................................................................25

Disputed Claims Process ...................................................................................................................................................25

Section 9 Definitions of Terms We Use in This Brochure ..........................................................................................................27

Annuitants .........................................................................................................................................................................27

BENEFEDS ......................................................................................................................................................................27

Benefits .............................................................................................................................................................................27

Enrollee .............................................................................................................................................................................27

FEDVIP .............................................................................................................................................................................27

Plan Allowance .................................................................................................................................................................27

Pre-Authorization ..............................................................................................................................................................27

Sponsor ..............................................................................................................................................................................27

TRICARE-eligible individual (TEI) certifying family member .......................................................................................27

TRICARE-eligible individual (TEI) family member ........................................................................................................27

We/Us ................................................................................................................................................................................27

You ....................................................................................................................................................................................27

Stop Health Care Fraud! .............................................................................................................................................................28

Summary of Benefits ..................................................................................................................................................................29

Rate Information .........................................................................................................................................................................31

3 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

FEDVIP Program Highlights

You can select from several nationwide, and in some areas, regional dental Preferred

Provider Organization (PPO) or Health Maintenance Organization (HMO) plans, and high

and standard coverage options. You can also select from several nationwide vision plans.

You may enroll in a dental plan or a vision plan, or both. Some TRICARE beneficiaries

may not be eligible to enroll in both. Visit www.opm.gov/dental or www.opm.gov/

vision for more information.

A Choice of Plans and

Options

You enroll online at www.BENEFEDS.com. Please see Section 2, Enrollment, for more

information.

Enroll Through

BENEFEDS

If you or one of your family members is enrolled in or covered by one FEDVIP plan, that

person cannot be enrolled in or covered as a family member by another FEDVIP plan

offering the same type of coverage; e.g., you (or covered family members) cannot be

covered by two FEDVIP dental plans or two FEDVIP vision plans.

Dual Enrollment

If you sign up for a dental and/or vision plan during the 2023 Open Season, your coverage

will begin on January 1, 2024. Premium deductions will start with the first full pay period

beginning on/after January 1, 2024. You may use your benefits as soon as your

enrollment is confirmed.

Coverage Effective Date

Employees automatically pay premiums through payroll deductions using pre-tax dollars.

Annuitants automatically pay premiums through annuity deductions using post-tax

dollars. TRICARE enrollees automatically pay premiums through payroll deduction or

automatic bank withdrawal (ABW) using post-tax dollars.

Pre-Tax Salary Deduction

for Employees

Each year, an Open Season will be held, during which you may enroll or change your

dental and/or vision plan enrollment. This year, Open Season runs from November 13,

2023 through midnight Eastern time December 11, 2023. You do not need to re-enroll

each Open Season unless you wish to change plans or plan options; your coverage will

continue from the previous year. In addition to the annual Open Season, there are certain

events that allow you to make specific types of enrollment changes throughout the year.

Please see Section 2, Enrollment, for more information.

Annual Enrollment

Opportunity

Your enrollment or your eligibility to enroll may continue after retirement. You do not

need to be enrolled in FEDVIP for any length of time to continue enrollment into

retirement. Your family members may also be able to continue enrollment after your

death. Please see Section 1, Eligibility, for more information.

Continued Group

Coverage After

Retirement

4 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

2024 Program Highlights

2024 Highlights

We Have Expanded Our Online Presence by Adding two New Retailers to our Network:

•LensCrafters.com

•TargetOptical.com

5 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

Section 1 Eligibility

If you are a Federal or U.S. Postal Service employee, you are eligible to enroll in FEDVIP,

if you are eligible for the Federal Employees Health Benefits (FEHB) Program or the

Health Insurance Marketplace (Exchange) and your position is not excluded by law or

regulation. Enrollment in the FEHB Program or the Health Insurance Marketplace

(Exchange) is not required.

Federal Employees

Certain temporary, intermittent, and seasonal Federal and U.S. Postal Service employees

are now eligible to enroll in FEDVIP. To be eligible, these employees must be expected to

work 130 hours per calendar month for at least 90 days. In addition, certain firefighters

hired under a temporary appointment and intermittent emergency response personnel are

eligible to enroll in FEDVIP. The employing agency must determine and notify these

employees of their eligibility.

Temporary/Seasonal

Employees

You are eligible to enroll if you:

• retired on an immediate annuity under the Civil Service Retirement System (CSRS),

the Federal Employees Retirement System (FERS), or another retirement system for

employees of the Federal Government;

• retired for disability under CSRS, FERS, or another retirement system for employees

of the Federal Government.

Your FEDVIP enrollment will continue into retirement, if you retire on an immediate

annuity or for disability under CSRS, FERS or another retirement system for employees

of the Government, regardless of the length of time you had FEDVIP coverage as an

employee. There is no requirement to have coverage for 5 years of service prior to

retirement in order to continue coverage into retirement, as there is with the FEHB

Program.

Your FEDVIP coverage will end if you retire on a Minimum Retirement Age (MRA) + 10

retirement and postpone receipt of your annuity. You may enroll in FEDVIP again when

you begin to receive your annuity.

Federal Annuitants

If you are a survivor of a deceased Federal/U.S. Postal Service employee or annuitant and

you are receiving an annuity, you may enroll or continue the existing enrollment.

Survivor Annuitants

A compensationer is someone receiving monthly compensation from the Department of

Labor’s Office of Workers’ Compensation Programs (OWCP) due to an on-the-job injury/

illness who is determined by the Secretary of Labor to be unable to return to duty. You are

eligible to enroll in FEDVIP or continue FEDVIP enrollment into compensation status.

Compensationers

An individual who is eligible for FEDVIP dental coverage based on the individual's

eligibility to previously be covered under the TRICARE Retiree Dental Program or an

individual eligible for FEDVIP vision coverage based on the individual's enrollment in a

specified TRICARE health plan.

Retired members of the uniformed services and National Guard/Reserve components,

including “gray-area” retirees under age 60 and their families are eligible for FEDVIP

dental coverage. These individuals, if enrolled in a TRICARE health plan, are also eligible

for FEDVIP vision coverage. In addition, uniformed services active-duty family members

who are enrolled in a TRICARE health plan are eligible for FEDVIP vision coverage.

TRICARE-eligible

individual

6 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

Except with respect to TRICARE-eligible individuals, family members include your

spouse and unmarried dependent children under age 22. This includes legally adopted

children and recognized natural children who meet certain dependency requirements.

This also includes stepchildren and foster children who live with you in a regular parent-

child relationship. Under certain circumstances, you may also continue coverage for a

disabled child 22 years of age or older who is incapable of self-support. FEDVIP rules

and FEHB rules for family member eligibility are NOT the same.

For more information on family member eligibility visit the website at www.opm.gov/

healthcare-insurance/dental-vision/ or contact your employing agency or retirement

system.

With respect to TRICARE-eligible individuals, family members include your spouse,

unremarried widow, unremarried widower, unmarried child, and certain unmarried

persons placed in your legal custody by a court. An unremarried former spouse who meets

the U.S. Department of Defense’s 20-20-20 and/or 20-20-15 benefit eligibility

requirements may only enroll in a self-only FEDVIP vision plan. Children include legally

adopted children, stepchildren, and pre-adoptive children. Children and dependent

unmarried persons must be under age 21 if they are not a student, under age 23 if they are

a full-time student, or incapable of self-support because of a mental or physical

incapacity.

Family Members

The following persons are not eligible to enroll in FEDVIP, regardless of FEHB eligibility

or receipt of an annuity or portion of an annuity:

• Deferred annuitants

• Former spouses of employees or annuitants. Note: Former spouses of TRICARE-

eligible individuals may enroll in a FEDVIP vision plan.

• FEHB Temporary Continuation of Coverage (TCC) enrollees

• Anyone receiving an insurable interest annuity who is not also an eligible family

member

• Active-duty uniformed service members. Note: If you are an active-duty uniformed

service member, your dental and vision coverage will be provided by TRICARE.

Your family members will still be eligible to enroll in the TRICARE Dental Plan

(TDP).

• Temporary/seasonal employees who do not meet the 130 hours per calendar month for

90 days.

Not Eligible

7 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

Section 2 Enrollment

You must use BENEFEDS to enroll or change enrollment in a FEDVIP plan. BENEFEDS is a

secure enrollment website (www.BENEFEDS.com) sponsored by OPM. If you do not have

access to a computer, call 1-877-888-FEDS (3337), TTY number 1-877-889-5680 to enroll or

change your enrollment.

If you are currently enrolled in a FEDVIP vision plan and want to switch to BCBS FEP

Vision, you must change enrollment through BENEFEDS. If you do not want to change plans

or options, your enrollment will continue automatically. Please note: your plan's premiums

may change for 2024.

Note: You cannot enroll or change enrollment in a FEDVIP plan using the Health Benefits Election

Form (SF 2809) or through an agency self-service system, such as Employee Express, PostalEase,

EBIS, MyPay, or Employee Personal Page. However, those sites may provide a link to

BENEFEDS.

Enroll Through

BENEFEDS

Self Only: A Self Only enrollment covers only you as the enrolled employee or annuitant. You

may choose a Self Only enrollment even though you have a family; however, your family members

will not be covered under FEDVIP.

Self Plus One: A Self Plus One enrollment covers you as the enrolled employee or annuitant plus

one eligible family member whom you specify. You may choose a Self Plus One enrollment even

though you have additional eligible family members, but the additional family members will not be

covered under FEDVIP.

Self and Family: A Self and Family enrollment covers you as the enrolled employee or annuitant

and all of your eligible family members. You must list all eligible family members when enrolling.

Enrollment Types

If you or one of your family members is enrolled in or covered by one FEDVIP plan, that person

cannot be enrolled in or covered as a family member by another FEDVIP plan offering the same

type of coverage; e.g., you (or covered family members) cannot be covered by two FEDVIP dental

plans or two FEDVIP vision plans.

Dual Enrollment

Open Season

If you are an eligible employee, annuitant, or TRICARE-eligible individual (TEI), you may enroll

in a dental and/or vision plan during the November 13, through midnight Eastern time December

11, 2023, Open Season. Coverage is effective January 1, 2024.

During future annual Open Seasons, you may enroll in a plan, or change or cancel your dental and/

or vision coverage. The effective date of these Open Season enrollments and changes will be set by

OPM. If you want to continue your current enrollment, do nothing. Your enrollment carries

over from year to year, unless you change it.

New hire/Newly eligible

You may enroll within 60 days after you become eligible as:

• a new employee;

• a previously ineligible employee who transferred to a covered position;

• a survivor annuitant if not already covered under FEDVIP;

• an employee returning to service following a break in service of at least 31 days; or

• a TRICARE-eligible individual

Your enrollment will be effective the first day of the pay period following the one in which

BENEFEDS receives and confirms your enrollment.

Opportunities to

Enroll or Change

Enrollment

8 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

Qualifying Life Event

A qualifying life event (QLE) is an event that allows you to enroll, or if you are already enrolled,

allows you to change your enrollment outside of an Open Season.

The following chart lists the QLEs and the enrollment actions you may take:

Qualifying Life Event: Marriage

From Not Enrolled to Enrolled: Yes

Increase Enrollment Type: Yes

Decrease Enrollment Type: No

Cancel: No

Change from One Plan to Another: Yes

Qualifying Life Event: Acquiring an eligible family member (non-spouse)

From Not Enrolled to Enrolled: No

Increase Enrollment Type: Yes

Decrease Enrollment Type: No

Cancel: No

Change from One Plan to Another: No

Qualifying Life Event: Losing a covered family member

From Not Enrolled to Enrolled: No

Increase Enrollment Type: No

Decrease Enrollment Type: Yes

Cancel: No

Change from One Plan to Another: No

Qualifying Life Event: Losing other dental/vision coverage (eligible or covered person)

From Not Enrolled to Enrolled: Yes

Increase Enrollment Type: Yes

Decrease Enrollment Type: No

Cancel: No

Change from One Plan to Another: No

Qualifying Life Event: Moving out of regional plan's service area

From Not Enrolled to Enrolled: No

Increase Enrollment Type: No

Decrease Enrollment Type: No

Cancel: No

Change from One Plan to Another: Yes

Qualifying Life Event: Going on active military duty, non-pay status (enrollee or spouse)

From Not Enrolled to Enrolled: No

Increase Enrollment Type: No

Decrease Enrollment Type: No

Cancel: Yes

Change from One Plan to Another: No

Qualifying Life Event: Returning to pay status from active military duty (enrollee or spouse)

From Not Enrolled to Enrolled: Yes

Increase Enrollment Type: No

Decrease Enrollment Type: No

Cancel: No

Change from One Plan to Another: No

Opportunities to

Enroll or Change

Enrollment

9 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

Qualifying Life Event: Returning to pay status from Leave without pay (LWOP)

From Not Enrolled to Enrolled: Yes (if enrollment cancelled during LWOP)

Increase Enrollment Type: No

Decrease Enrollment Type: No

Cancel: No

Change from One Plan to Another: Yes (if enrollment cancelled during LWOP)

Qualifying Life Event: Annuity/compensation restored

From Not Enrolled to Enrolled: Yes

Increase Enrollment Type: No

Decrease Enrollment Type: No

Cancel: No

Change from One Plan to Another: No

Qualifying Life Event: Transferring to an eligible position*

From Not Enrolled to Enrolled: No

Increase Enrollment Type: No

Decrease Enrollment Type: No

Cancel: Yes

Change from One Plan to Another: No

*Position must be in a Federal agency that provides dental and/or vision coverage with 50 percent

or more employer-paid premium.

The timeframe for requesting a QLE change is from 31 days before to 60 days after the event.

There are two exceptions:

• There is no time limit for a change based on moving from a regional plan’s service area.

• You cannot request a new enrollment based on a QLE before the QLE occurs, except for

enrollment because of loss of dental or vision insurance. You must make the change no later than

60 days after the event.

Enrollments and enrollment changes made based on a QLE are effective on the first day of the pay

period following the one in which BENEFEDS receives and confirms the enrollment or change.

BENEFEDS will send you confirmation of your new coverage effective date.

Once you enroll in a plan, your 60-day window for that type of plan ends, even if 60 calendar days

have not yet elapsed. That means once you have enrolled in either a dental or a vision plan, you

cannot change or cancel that particular enrollment until the next Open Season, unless you

experience a QLE that allows such a change or cancellation.

VA Exception for Cancellation

Generally, you may cancel your enrollment only during the annual Open Season. However, if you

are a FEDVIP enrollee paying premiums on a post-tax basis, and you, your family member, or TEI

family member becomes eligible for VA dental or vision benefits, then you may change your

enrollment type or cancel your enrollment within 60 days of receiving notification of VA dental or

vision eligibility. This 60-day period may fall outside of Open Season. VA dental or vision

eligibility documentation must be submitted to OPM via the BENEFEDS mailbox

([email protected]) within 60 days of notification to support the FEDVIP enrollment

change or cancellation.

Your cancellation is effective at the end of the day before the date OPM sets as the Open Season

effective date. An eligible family member’s coverage also ends upon the effective date of the

cancellation.

If you are a FEDVIP enrollee paying premiums on a pre-tax basis, and you, your family member,

or TEI family member becomes eligible for VA dental or vision benefits, then you may not change

or cancel your FEDVIP enrollment until the next Open Season.

Opportunities to

Enroll or Change

Enrollment

10 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

FEDVIP enrollees can verify if they are paying their premiums on a pre- or post-tax basis by

contacting BENEFEDS at 1-877-888-FEDS (3337), TTY number 1-877-889-5680.

11 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

Coverage ends for active and retired Federal, U.S. Postal employees, and TRICARE-eligible

individuals when:

• you no longer meet the definition of an eligible employee, annuitant, or TRICARE-eligible

individual;

• as a Retired Reservist you begin active duty;

• a sponsor or primary enrollee leaves active duty;

• you begin a period of non-pay status or pay that is insufficient to have your FEDVIP premiums

withheld and you do not make direct premium payments to BENEFEDS;

• you are making direct premium payments to BENEFEDS and you stop making the payments;

• it is the last day of the pay period for which BENEFEDS received premium following the loss

of eligibility;

• you cancel the enrollment during Open Season.

Coverage for a family member ends when:

• you as the enrollee lose coverage; or

• the family member no longer meets the definition of an eligible family member.

When Coverage

Stops

Under FEDVIP, there is no 31-day extension of coverage. The following are also NOT

available under the FEDVIP plans:

• Temporary Continuation of Coverage (TCC);

• spouse equity coverage; or

• right to convert to an individual policy (conversion policy).

Continuation of

Coverage

If you are planning to enroll in an FSAFEDS Health Care Flexible Spending Account (HCFSA) or

Limited Expense Health Care Flexible Spending Account (LEX HCFSA), you should consider how

coverage under a FEDVIP plan will affect your annual expenses, and thus the amount that you

should allot to an FSAFEDS account. Please note that insurance premiums are not eligible

expenses for either type of FSA.

Please review IRS - Publication 969, Health Savings Accounts and Other Tax-Favored Health

Plans (www.irs.gov/forms-pubs/about-publication-969) for additional information about carryover

and contribution amounts for the upcoming tax year. If you have an HCFSA or LEX HCFSA

FSAFEDS account and you have not exhausted your funds by December 31st of the plan year,

FSAFEDS can automatically carry over a set maximum amount of unspent funds into another

health care or limited expense account for the subsequent year. To be eligible for carryover, you

must be employed by an agency that participates in FSAFEDS and actively making allotments

from your pay through December 31st. You must also actively re-enroll in a health care or limited

expense account during the next Open Season to be carryover eligible. Your re-enrollment must

meet the minimum contribution amount for the plan year. If you do not re-enroll, or if you are not

employed by an agency that participates in FSAFEDS and actively making allotments from your

pay through December 31st, your funds will not be carried over.

Because of the tax benefits an FSA provides, the IRS requires that you forfeit any money for which

you did not incur an eligible expense and file a claim in the time permitted. This is known as the

“Use-it-or-Lose-it” rule. Carefully consider the amount you will elect.

Current FSAFEDS participants must re-enroll to participate in the program next year.

See www.fsafeds.com or call 1-877-FSAFEDS (372-3337) or TTY: 1-866-353-8058. Note:

FSAFEDS is not open to retired employees or to TRICARE eligible individuals.

If you enroll or are enrolled in a high deductible health plan with a health savings account (HSA) or

health reimbursement arrangement (HRA), you may use your HSA or HRA to pay for qualified

dental/vision costs not covered by your FEHB and/or FEDVIP plans.

FSAFEDS/High

Deductible Health

Plans and FEDVIP

12 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

Section 3 How You Obtain Care

Two ID cards are issued for each member, regardless of coverage option. Existing members' ID

cards are still valid. If additional cards are needed, you may request them through our website,

www.bcbsfepvision.com, or call us at 1-888-550-BLUE (2583) or TTY: 1-800-523-2847. All

eligible dependents listed on your enrollment share your identification number. You do not need

an ID card for each member of your family. You can print a temporary ID card online in our

member portal at www.bcbsfepvision.com/portal, view it in our mobile app or contact customer

service to verify your eligibility in the plan.

Identification

Cards/Enrollment

Confirmation

We list in-network plan providers in the provider directory, which is updated frequently. The

most current list can be found on our website at www.bcbsfepvision.com. It is your

responsibility to ensure that the provider chosen is an active participant in the program, at the

time you receive services. The BCBS FEP Vision network is specific to routine vision care

and is different from the network for your medical plan.

In some cases, due to local regulations or business practices, the doctor may be independent of

the retail location. You should confirm that both the doctor and the retail location are

participating prior to seeking services.

Plan Providers

We negotiate rates with vision care providers to help save you money. BCBS FEP Vision in-

network providers are referred to as participating providers and are contracted through Davis

Vision. When scheduling an appointment, you should identify yourself as a member of the

FEDVIP BCBS FEP Vision plan. The provider is then responsible for verifying eligibility and

submitting the claim by contacting BCBS FEP Vision either by telephone or via the web. If you

use a participating provider to obtain covered care, benefits are paid at the in-network level. You

are responsible for amounts over the plan allowance, lens copays, and optional lens and

treatment copays.

BCBS FEP Vision also offers several in-network online options such as: 1800contacts.com,

befitting.com, glasses.com, lenscrafters.com, targetoptical.com, visionworks.com and

warbyparker.com. Check our website at www.bcbsfepvision.com for additional options.

Under Standard Option, you must stay in-network for covered services. If you receive care from

a non-participating provider, we will not pay for any services unless you reside in a limited

access area. Please see Section 4, Your Cost For Covered Services.

In-Network

Under High Option, you may obtain care from any licensed eye care provider. If the provider

you use is not part of our network, benefits will be considered out-of-network. Because these

providers are out of the BCBS FEP Vision network, we will reimburse you up to the maximum

reimbursement amount allowed by the plan (see fee schedule allowances as described in Section

4, Your Cost For Covered Services). You are responsible to pay the out-of-network provider and

then submit a claim along with an itemized receipt to receive your reimbursement (see Section

8, Claims Filing and Disputed Claims Processes, for information).

Under Standard Option, you must stay in-network for covered services. If you receive care from

a non-participating provider, we will not pay for any services unless you reside in a limited

access area. Please see Section 4, Your Cost For Covered Services.

Out-of-Network

Pre-authorization is only required for:

• Medically necessary contact lenses in the treatment of certain eye health conditions and is

obtained by the participating provider.

• The treatment of low vision and is obtained by the participating provider.

• The child benefit for children 13 and under if their prescription changes.

• The condition benefit for members with certain conditions (diabetes, hypertension, kidney

disease, dementia, pregnancy, HNCRT (Head and Neck Cancer Patients with Radiation

Therapy) if their prescription changes.

Pre-Authorization

13 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

When you visit a provider who participates with both your FEHB plan and your FEDVIP plan,

and the FEHB plan provides routine vision care and services, the FEHB plan will pay benefits

first. The FEDVIP plan allowance will be the prevailing charge in these cases. You are

responsible for the difference between the FEHB and FEDVIP benefit payments and the

FEDVIP plan allowance. We are responsible for facilitating the process with the primary FEHB

payor.

FEHB First Payor

We do not coordinate benefits with non-FEHB health plans. Coordination of

Benefits

If you live in an area that does not have adequate access to an BCBS FEP Vision network

provider and you receive covered services from an out-of-network provider, we will pay up to

100% of our plan allowance listed below. You are responsible for any difference between the

amount billed and our payment. To determine if you are in a limited access area call us

at 1-888-550-BLUE (2583) or TTY: 1-800-523-2847.

Members who reside in areas not meeting access standards* can visit an out-of-network

provider, pay billed charges and then be reimbursed based on the plan allowance.

*NOTE: Access Standards

Urban and suburban Zip Codes: at least 90% of FEDVIP eligibles in a network access area (Zip

Code plus 15 driving-miles) must have access to a vision care preferred provider.

Rural Zip Codes: at least 80% of FEDVIP eligibles in a network access area (Zip Code plus 35

driving-miles) must have access to a vision care preferred provider.

Plan Allowance: The maximum benefit payment for services provided in areas not meeting the

access standards are shown in the chart below. You are responsible for charges billed over the

amounts shown.

Services/Material: Vision Care Exam

High Option: We pay up to $50

Standard Option: We pay up to $50

Services/Material: Single Vision Lenses

High Option: We pay up to $72

Standard Option: We pay up to $72

Services/Material: Bifocal Lenses

High Option: We pay up to $109

Standard Option: We pay up to $109

Services/Material: Trifocal Lenses

High Option: We pay up to $136

Standard Option: We pay up to $136

Services/Material: Lenticular Lenses

High Option: We pay up to $136

Standard Option: We pay up to $136

Services/Material: Contact Lenses

High Option: We pay up to $150

Standard Option: We pay up to $140

Services/Material: Medically Necessary Contact Lenses

High Option: We pay up to $600

Standard Option: We pay up to $600

Services/Material: Frames

High Option: We pay up to $200

Standard Option: We pay up to $140

Limited

Access Areas

14 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

Section 4 Your Cost for Covered Services

This is what you pay out-of-pocket for covered care:

A co-payment is a fixed amount of money you pay to the provider when you receive

services.

Example: The BCBS FEP Vision High Option and Standard Option plans have a $0 copay

for a vision care exam. However, Standard Option has a $10 copay for lenses. This copay

does not apply to High Option. Please refer to Section 5 for further details.

Copayment

When you visit a BCBS FEP Vision network doctor, your vision care exam is covered in

full and prescription glasses or contacts are covered after any co-payments. If you visit an

in-network independent provider, you will also receive 20% off any out-of-pocket costs

over your frame allowance and a savings of 15% on any balance over your conventional

contact allowance. To receive covered benefits, you must stay in-network if you are

enrolled in Standard Option.

In-Network Services

If you are enrolled in Standard Option, you must stay in-network for covered services. If

you receive care from a non-participating provider, we will not pay for any services unless

you reside in a limited access area. Please see details described in (Section 3, How to

Obtain Care) for information on limited access areas.

If you are enrolled in High Option, you’ll get more out of your coverage and pay lower

out-of-pocket costs when you see a BCBS FEP Vision network provider. Plus, there are

no claim forms to submit when you see an in-network provider. When you visit an out-of-

network provider, you will be reimbursed according to the schedule shown in the chart

below. Only items listed in the chart below are reimbursable. You will be responsible for

charges billed over the amounts shown.

Services/Material: Vision Care Exam

We Pay: Up to $30

Services/Material: Single Vision Lenses

We Pay: Up to $25

Services/Material: Bifocal Lenses

We Pay: Up to $35

Services/Material: Trifocal Lenses

We Pay: Up to $45

Services/Material: Lenticular Lenses

We Pay: Up to $45

Services/Material: Elective Contact Lenses

We Pay: Up to $75

Services/Material: Medically Necessary Contact Lenses

We Pay: Up to $225

Services/Material: Frames

We Pay: Up to $30

Out-of-Network Services

15 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

Section 5 Vision Services and Supplies

Important things you should keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and

are payable only when we determine they are necessary for the prevention, diagnosis, care or treatment of a

covered condition and meet generally accepted protocols.

•All BCBS FEP Vision independent providers are required to extend a 20% discount to all members that

purchase additional frames, and/or spectacle lenses and/or daily wear contact lenses, and a 10% discount

when purchasing additional disposable contact lenses. This discount can either be in conjunction with their

benefit (pair 2, 3, etc.) or at any other time. The materials portion of the member’s benefit does not need to be

exhausted first in order for the member to receive this discount.

•We offer additional benefits for children age 13 and under. See full details below.

•We offer additional benefits for members with specific conditions (e.g., diabetes, hypertension) see full

details below.

•We offer an additional $50 frame allowance at MyEyeDr. High Option members have a $250 allowance and

Standard Option members have a $190 allowance at all MyEyeDr. locations.

•We added lenscrafters.com and targetoptical.com to our online network.

Benefit Description You Pay

Diagnostic High Option Standard Option

Vision Care Exam: covered in full once every calendar

year.

• Includes dilation, if professionally indicated

• Includes refraction only if vision health exam is billed to

medical

BCBS FEP Vision doctors provide a comprehensive exam

that focuses on your eye health and overall wellness

In-Network: Nothing

Out-of-Network: Expenses in

excess of the fee schedule

allowance of $30

In-Network: Nothing

Out-of-Network: All charges

Retinal ImagingIn-Network: $39 copay

Out-of-Network: All charges

In-Network: $39 copay

Out-of-Network: All charges

Eyewear High Option Standard Option

Lenses: one pair every calendar year.

Lenses include choice of glass or plastic lenses, all lens

powers (single vision, bifocal, trifocal, lenticular), fashion

and gradient tinting, ultraviolet protective coating,

oversized and glass-grey #3 prescription sunglass lenses.

Note: All lenses include scratch-resistant coating with no

additional copayment. There may be an additional charge

at in-network national and online retailers.

Note: You may choose prescription glasses or contacts.

In-Network: Nothing

Out-of-Network: Expenses in

excess of fee schedule allowance

of:

$25 single vision

$35 bifocal

$45 trifocal

$45 lenticular

In-Network: $10 copay

Out-of-Network: All charges

Eyewear - continued on next page

16 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

Benefit Description You Pay

Eyewear (cont.) High Option Standard Option

Optional Lenses and TreatmentsIn-Network Only In-Network Only

Anti-Reflective (AR) Coatings - Standard/Premium/Ultra/

Ultimate

$20/$33/$45/$70$35/$48/$60/$85

Blended Segment Lenses $20 $20

Blue Light Filtering Lenses$15$15

Digital single vision & computer lenses$30$30

Edge Polish$22$22

Hi-Index Lenses (1.67/1.74)$55/$120$55/$120

High Luster Edge Polish$70$70

Intermediate Vision Lenses $30 $30

Mirror Coating$86$86

Photochromic Glass Lenses $20 $20

Plastic Photosensitive Lenses (Transitions®) No-Copay $65

Polarized Lenses $75 $75

Polycarbonate Lenses No-Copay No-Copay

Premium Scratch Resistant$30$30

Progressives Lenses - Standard/Premium/Ultra/Ultimate$0/$40/$90/$125$50/$90/$140/$175

Rimless Drill$66$66

Roll & Polish$16$16

Roll Edge$24$24

Scratch Protection Plan $0$0

Scratch Resistant Coating$0$0

Scratch Resistant Premium $30$30

Slab Off$186$186

Specialty Lens (myodisc/double sided grind) and

Lenticular)

$206$206

Tinted LensesNo-CopayNo-Copay

Trivex Lenses$50$50

Ultraviolet Protective Coating No-Copay No-Copay

Frames: covered once every calendar year.

Receive an additional $50 towards your frame allowance

at MyEyeDr. locations.

*Note: Additional discounts are available from in-

network independent providers. In-network national and

online retailers do not offer the discount.

Note: “Collection” frames with retail values up to $195

are available at no cost at most in-network independent

providers. Retail chain providers typically do not display

the “Collection,” but are required to maintain a

comparable selection of frames that are covered in full.

In-Network:

Collection Frames: Nothing

Nothing for frames up to $200

frame allowance. Additionally, a

20% discount applies to any

amount over $200*

$250 frame allowance at

MyEyeDr. locations. The

additional 20% discount does not

apply.

Out-of-Network: Expenses in

excess of fee schedule allowance

of $30

In-Network:

Collection Frames: Nothing

Nothing for frames up to $140

frame allowance. Additionally, a

20% discount applies to any

amount over $140*

$190 frame allowance at

MyEyeDr. locations. Additional

20% discount does not apply.

Out-of-Network: All charges

17 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

Benefit Description You Pay

Contact Lenses High Option Standard Option

Contact Lenses: covered once every calendar year – in

lieu of eyeglasses.

*Note: Additional discounts are available from in-

network independent providers. In-network national and

online retailers do not offer the discount.

**Note: Pre-authorization is required.

In-Network:

Expenses in excess of a $150

allowance. Additionally, a 15%

discount applies to any amount

over $150.*

The evaluation, fitting and follow-

up care is covered in full for Non-

Specialty contact lenses. For

Specialty lenses (including, but

not limited to, toric, multifocal

and gas permeable lenses), you

receive $60 toward the contact

lens evaluation and fitting, plus a

15% discount off the balance over

$60*. Participating providers will

bill you for anything over the $60

less the discount so you do not

have to file a claim.

Expenses in excess of $600 for

medically necessary contact

lenses.**

Out-of-Network: Expenses in

excess of fee schedule allowance

of:

$75 elective contact lenses

$225 medically necessary contact

lenses

In-Network:

Expenses in excess of a $140

allowance. Additionally, a 15%

discount applies to any amount

over $140.*

The cost of the evaluation, fitting

and follow-up care is not covered.

The remaining balance of a $140

allowance after purchasing

contact lenses may be applied

toward the cost of evaluation,

materials, fitting, and follow up

care.

Participating providers usually

charge separately for the

evaluation, fitting, or follow-up

care relating to contact

lenses. When this occurs and the

value of the contact lenses

received is less than

the allowance, you may submit a

claim for the remaining balance

(the combined reimbursement will

not exceed $140).

Expenses in excess of $600 for

medically necessary contact

lenses.**

Out-of-Network: All charges

Warranty

BCBS FEP Vision “Collection” frames and all eyeglass lenses manufactured in BCBS FEP Vision laboratories are guaranteed for

one year from the original date of dispensing. Warranty limitations may apply to provider or retailer supplied frames and/or

eyeglass lenses. Please ask your provider for details of the warranty that is available to you.

Child Benefit

Benefit applies to children 13 years of age and under.

In-Network Only – High Option and Standard Option

One additional vision care exam is covered in full every calendar year.

If the child's prescription changes, one additional pair of lenses is covered in full for High Option members; there is a $10 copay for

Standard Option members. Also, one additional pair of frames is covered if the child's prescription changes, with Collection frames

covered in full and non-Collection frames subject to the allowance, plus a 20% discount on any amount over the allowance.

The prescription must have changed at least a 0.5 diopter or the seg height changed at least a 5.0 millimeter, or lens type changed,

e.g. (from single vision to bifocal). Pre-authorization is required.

18 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

Medical Condition Benefit

This benefit provides additional coverage to members who have been diagnosed with the following conditions: diabetes,

hypertension, kidney disease, dementia, pregnancy, HNCRT (Head and Neck Cancer Patients with Radiation Therapy).

In-Network Only - High Option and Standard Option

One additional vision care exam is covered in full every calendar year.

If the prescription changes, one additional pair of lenses is covered in full for High Option members; there is a $10 copay for

Standard Option members.

The prescription must have changed at least 0.5 diopter or the seg height changed at least a 5.0 millimeter, or lens type changed, e.g.

(from single vision to bifocal). Pre-authorization is required.

Low Vision

Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in

low vision care can evaluate and prescribe optical devices, and provide training and instruction to maximize the remaining usable

vision for our members with low vision. After pre-authorization by BCBS FEP Vision, covered low vision services (both in- and

out-of-network) will include one comprehensive low vision evaluation every five years, with a maximum charge of $300; maximum

low vision aid allowance of $600 with a lifetime maximum of $1,200 for items such as high-power spectacles, magnifiers and

telescopes; and follow-up care – four visits in any five-year period, with a maximum charge of $100 each visit. Digital devices

such as iPads, cell phones, etc. are not covered. Participating providers will obtain the necessary pre-authorization for these

services.

Medically Necessary Contact Lenses

Medically Necessary Contact Lenses: Contact lenses may be determined to be medically necessary and appropriate in the

treatment of patients affected by certain conditions. Clinical documentation may be requested from your doctor to support the

medically necessary contact lenses. Contact lenses may be determined to be medically necessary in the treatment of specific eye

conditions such as:

Keratoconus

High Ametropia

Anisometropia

Aphakia

Aniridia

Moderate to Severe Dry Eye Disease

Irregular Astigmatism

Having the diagnosis of a particular eye condition does not guarantee that the contact lenses would be determined to be medically

necessary per the criteria outlined in the clinical guidelines.

19 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

Discounts

Save with Blue365® Discounts

BCBS FEP Vision presents Blue365, a program that provides easy access to premier health and wellness products and services to

help members build a path to live a healthy life. With Blue365, members get access to over 90 handpicked discounts from leading

brands and there is no limit to how many deals a member can redeem. Many deals are available and new ones are constantly being

added, including:

• Fitness – Get the support you need to achieve your fitness goals with deals on wearable devices, apparel, home gym equipment,

virtual workout classes and in-person gym access.

• Healthy Eyes and Ears – Between replacing hearing aids and correcting your vision, caring for your eyes and ears can get

expensive quickly. Blue365 provides up to 60% off hearing aids, discounts on LASIK surgery and more.

• Home and Family – Your home and family can influence your mental, physical, emotional, and financial well-being. Blue365

offers discounts on premium vitamins and supplements, pet insurance, fertility services, products for new parents, financial

offers, family health and more.

• Nutrition – Blue365 offers a variety of deals that help you eat right. Choose from meal kit subscriptions, chef-prepared entrees,

weight management plans and more.

• Personal Care – A little self-care can go a long way toward improving your mental health. Blue365 offers exclusive discounts on

skin care products, oral care products, tooth-whitening kits, mindfulness subscriptions and much more.

• Travel – Sometimes a vacation is all you need to escape stress and reset. Blue365 makes family getaways more affordable with

discounted access to lodging, car rentals and vacation packages.

Each week, Blue365 members can receive great health and wellness deals via email. With Blue365, there is no paperwork to fill

out. Just visit http://www.bcbsfepvision.com/additional-discounts and select Visit Blue365 deals to learn more about the various

Blue365 vendors and discounts. BCBS FEP Vision does not recommend, endorse, warrant, or guarantee any specific Blue365

vendor or item. Vendors and the program are subject to change at any time.

Laser Vision Correction: BCBS FEP Vision members can realize substantial discounts on laser correction procedures using the

QualSight Network. For more details visit our website at https://bcbsfepvision.com/lasik/.

Your Hearing Network: BCBS FEP Vision members have access to a hearing health care program through Your Hearing Network

(YHN). For more details visit our website at https://bcbsfepvision.com/additional-discounts/.

20 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

Tools and Resources

Vision Simulator

Description: Experience vision issues with the Vision Simulator: See through the eyes of someone affected by glaucoma, cataract,

diabetic retinopathy, presbyopia, glare, and macular degeneration, and experience the impact these common conditions have on

sight. How would your daily activities be impacted? What moments would you lose? Whose faces would you miss? Try our

vision simulator by visiting https://bcbsfepvision.com/visionsimulator.

Virtual Frame Try-on

Description: Our frame try-on tool allows you to try our Exclusive Collection frames from the convenience of your phone, tablet,

or computer. Use your webcam to see what the frames look like on you or you can select a model. Try our virtual frame try-on tool

by visiting https://bcbsfepvision.com/frametryon.

AskBlue BCBS FEP Vision Plan Finder

Description: Need help choosing between High Option and Standard Option? AskBlue makes it easy. In just 10 minutes, you can

answer some simple questions and get recommended a plan based on your needs.

Try AskBlue by visiting https://askblue.bcbsfepvision.com

Member Portal

Description: Visit our member portal at www.bcbsfepvision.com/portal to, view your benefits, locate an in-network provider, check

the status of your claims, request claim forms, and request a duplicate or replacement ID card. Additional features include:

• Online EOBs – You can view, download, and print your Explanation of Benefits (EOB) forms.

Simply log on to www.bcbsfepvision.com/portal, enter your credentials, and from there you can search claims and select the

“EOB” link next to each claim to access your EOB. You can also access EOBs via the bcbsfepvision mobile app.

• Check eligibility – You can verify all the eligible members on your account.

• Submit an out-of-network claim – If you choose to see an out-of-network provider you can submit your claim online in the

member portal or via the bcbsfepvision mobile app.

• Shop online retailers – You can access our online retail partners' websites by clicking on the retailer's name.

BCBS FEP Vision Mobile Application

Description: BCBS FEP Vision’s mobile application is available for download for both iOS and Android mobile phones. The

application provides members with 24/7 access to helpful features, tools and information related to BCBS FEP Vision benefits.

They can log in with their username and password to access personal eye care information such as benefits, out-of-pocket costs, and

wellness information. They can also view claims and approval status, view/share Explanations of Benefits (EOBs), view/share

member ID cards, locate in-network providers and shop online retailers.

Social Media

Description: Follow us @bcbsfepvision on Facebook and YouTube for the latest information happening at BCBS FEP Vision.

Virtual Experience

Description: We’re thrilled to offer a unique, one-of-a-kind virtual experience! Don’t miss this engaging, entertaining and

educational experience for you to explore more about our vision care plans. View this virtual experience on your computer or

mobile device by going to https://bcbsfepvision.com/experience/.

21 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

Section 6 International Services and Supplies

If you travel or live outside the United States and Puerto Rico, you are still entitled to the benefits described in this brochure.

Unless otherwise noted in this section, the same definitions, limitations, and exclusions also apply.

Please note that pre-authorization does not apply when you receive care outside of the United States and Puerto Rico. You or

your provider must submit an explanation of medical necessity for the services listed in Section 3, How You Obtain Care,

when you receive these services outside of the United States and Puerto Rico.

For professional care you receive overseas, we provide benefits as indicated below. You

are responsible for any difference between our payment and the amount billed, in addition

to any copayment amounts. You must also pay any charges for non-covered services.

International Claims

Payment

We do not maintain a network of providers outside the United States and Puerto Rico.

You may visit any international provider of your choice and be reimbursed up to the

amount listed under "International Plan Allowances" below.

Finding an International

Provider

International providers are under no obligation to file claims on behalf of our members.

You may need to pay for the services at the time you receive them and then submit a

claim along with an itemized receipt to us for reimbursement. Claim forms are

available at www.bcbsfepvision.com or via email at [email protected].

To file a claim for covered vision care services received outside the United States and

Puerto Rico, send completed claim forms and itemized receipts to:

Blue Cross Blue Shield FEP Vision

P.O. Box 2010

Latham, New York 12110-2010

Or you may fax your claim to 518-220-6555. Please contact us at

[email protected] to let us know you would like to submit your claim via

email. We will respond with instructions on how to securely submit your claim.

Filing International

Claims

at 1-518-220-6569, TTY: 1-800-523-2847.

Customer Service

Website and Phone

Numbers

You may need to pay the provider in-full at the time of service and you will be reimbursed

up to the amounts shown below:

Services/Material: Vision Care Exam

High Option: We pay up to $60

Standard Option: We pay up to $60

Services/Material: Single Vision Lenses

High Option: We pay up to $72

Standard Option: We pay up to $72

Services/Material: Bifocal Lenses

High Option: We pay up to $109

Standard Option: We pay up to $109

Services/Material: Trifocal Lenses

High Option: We pay up to $136

Standard Option: We pay up to $136

Services/Material: Lenticular Lenses

High Option: We pay up to $136

Standard Option: We pay up to $136

International Plan

Allowances

22 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

Services/Material: Contact Lenses

High Option: We pay up to $150

Standard Option: We pay up to $140

Services/Material: Medically Necessary Contact Lenses

High Option: We pay up to $600

Standard Option: We pay up to $600

Services/Material: Frames

High Option: We pay up to $200

Standard Option: We pay up to $140

23 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

Section 7 General Exclusions – Things We Do Not Cover

The exclusions in this section apply to all benefits.

We do not cover the following:

•Services provided by non-participating providers for Standard Option members;

•Any charges in excess of the benefit, dollar, or supply limits stated in this brochure;

•Any vision service, treatment or materials not specifically listed as a covered service;

•Any exams given during your stay in a hospital or other facility for medical care;

•Drugs or medicines;

•Services and materials that are experimental or investigational;

•Services or materials that are rendered prior to your effective date;

•Services and materials incurred after the termination date of your coverage unless otherwise indicated;

•Services and materials not meeting accepted standards of optometric practice;

•Services and materials resulting from your failure to comply with professionally prescribed treatment;

•Benefits may not be combined with any discount or promotional offering unless otherwise noted in an offer;

•Telephone consultations;

•Any charges for failure to keep a scheduled appointment;

•Any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or

characterization of prosthetic appliances;

•Services or materials provided as a result of intentionally self-inflicted injury or illness;

•Services or materials provided as a result of injuries suffered while committing or attempting to commit a felony, engaging

in an illegal occupation, or participating in a riot, rebellion or insurrection;

•Office infection control charges;

•Charges for copies of your records, charts, or any costs associated with forwarding/mailing copies of your records or

charts;

•State or territorial taxes on vision services and materials;

•Medical treatment of eye disease or injury;

•Special vision procedures, such as orthoptics, vision therapy or vision training;

•Special lens designs or coatings other than those described in this brochure;

•Special supplies such as nonprescription sunglasses and subnormal vision aids;

•Replacement of lost/stolen eyewear;

•Non-prescription (Plano) lenses;

•Two pairs of eyeglasses in lieu of bifocals;

•Services not performed by licensed personnel;

•Prosthetic devices and services or digital devices such as iPads, cell phones, etc.

•Insurance of contact lenses;

•Professional services you receive from immediate relatives or household members, such as a spouse, parent, child, sibling,

by blood, marriage or adoption;

•Deductibles, copayments and coinsurance for medical services or other insurance are not reimbursable.

24 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

Section 8 Claims Filing and Disputed Claims Processes

If your vision care provider is participating in our network, they will file the claim for

you, and we will send payment directly to the vision care provider.

If you live in a limited access area, overseas or if you obtain services from a non-

participating provider (High Option only), you are responsible for filing the claim.

You can submit your out-of-network claim electronically using the mobile app, member

portal on our website, or you can obtain claim forms on the website at

www.bcbsfepvision.com or by calling 1-888-550-BLUE (2583) or TTY: 1-800-523-2847.

You can also submit an out-of-network claim form along with copies of the provider’s

bills by mail to:

Blue Cross Blue Shield FEP Vision

P.O. Box 2010

Latham, New York 12110-2010

How to File a Claim for

Covered Services

Out-of-network claims (High Option only), international claims, and claims incurred in

limited access areas must be submitted to and received by BCBS FEP Vision within 12

months of the date of service for reimbursement.

Deadline for Filing Your

Claim

Follow this disputed claims process if you disagree with our decision on your claim or

request for services. The FEDVIP law does not provide a role for OPM to review

disputed claims.

Disputed Claim Steps:

1. Ask us in writing to reconsider our initial decision. You must:

a) Write to us within 6 months from the date of our decision; and

b) Send your request to us at the address shown below; and

c) Include a statement about why you believe our initial decision was wrong, based

on specific benefit provisions in this brochure; and

d) Include copies of documents that support your claim, such as doctor's letters, and

Explanation of Benefits (EOB) forms.

Blue Cross Blue Shield FEP Vision

P.O. Box 2010

Latham, New York 12110-2010

FAX: 1-800-403-1783

Email: [email protected]

2. We have 30 days from the date we receive your request to:

a) Pay the claim or

b) Write to you and maintain our denial or

c) Ask you or your provider for more information.

You or your provider must send the information so that we receive it within 60 days of our

request. We will then decide within 30 more days. If we do not receive the information

within 60 days, we will decide within 30 days of the date the information was due. We

will base our decision on the information we already have. We will write to you with our

decision.

3. If the dispute is not resolved through the reconsideration process, you may request a

review of the denial. We will make a decision within 35 days of the date we receive your

request in writing.

Disputed Claims Process

25 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

4. If you do not agree with our final decision, you may request an independent third party,

mutually agreed upon by us and OPM, review the decision. The decision of the

independent third party is binding on us and is the final administrative review of your

claim. This decision is not subject to judicial review.

26 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

Section 9 Definitions of Terms We Use in This Brochure

Federal retirees (who retired on an immediate annuity), and survivors (of those who

retired on an immediate annuity or died in service) receiving an annuity. This also

includes those receiving compensation from the Department of Labor’s Office of

Workers’ Compensation Programs, who are called compensationers. Annuitants are

sometimes called retirees.

Annuitants

The enrollment and premium administration system for FEDVIP. BENEFEDS

Covered services or payment for covered services to which enrollees and covered family

members are entitled to the extent provided by this brochure.

Benefits

The Federal employee, annuitant, or TRICARE-eligible individual enrolled in this plan. Enrollee

Federal Employees Dental and Vision Insurance Program. FEDVIP

The maximum benefit payment for services received. Please refer to Section 4, Your Cost

for Covered Services, for the maximum benefit payment for services received in limited

access areas or out-of-network and Section 6, International Services and Supplies, for

services received outside the United States or Puerto Rico.

Plan Allowance

This is the procedure used by BCBS FEP Vision to pre-approve services and the amount

that BCBS FEP Vision will cover.

Pre-Authorization

Generally, a sponsor means the individual who is eligible for medical or dental benefits

under 10 U.S.C. chapter 55 based on their direct affiliation with the uniformed services

(including military members of the National Guard and Reserves).

Sponsor

Under circumstances where a sponsor is not an enrollee, a TEI family member may accept

responsibility to self-certify as an enrollee and enroll TEI family members.

TRICARE-eligible

individual (TEI)

certifying family member

TEI family members include a sponsor’s spouse, unremarried widow, unremarried

widower, unmarried child, and certain unmarried persons placed in a sponsor’s legal

custody by a court. Children include legally adopted children, stepchildren, and pre-

adoptive children. Children and dependent unmarried persons must be under age 21 if

they are not a student, and under age 23 if they are a full-time student or incapable of self-

support because of a mental or physical incapacity.

TRICARE-eligible

individual (TEI) family

member

Blue Cross Blue Shield FEP Vision. We/Us

Enrollee or eligible family member. You

27 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

Stop Health Care Fraud!

Fraud increases the cost of health care for everyone and increases your Federal Employees Dental and Vision Insurance

Program premium.

Protect Yourself From Fraud – Here are some things that you can do to prevent fraud:

•Do not give your BCBS FEP Vision identification (ID) number over the telephone or to people you do not know, except to

your providers, plan, BENEFEDS or OPM.

•Let only the appropriate providers review your clinical record or recommend services.

•Avoid using providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.

•Carefully review your Explanation of Benefits (EOBs) statements, which are available online at www.bcbsfepvision.com.

•Do not ask your provider to make false entries on certificates, bills or records in order to get us to pay for an item or

service.

•If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or

misrepresented any information, do the following:

- Call the provider and ask for an explanation. There may be an error.

- If the provider does not resolve the matter, call us at 1-888-550-BLUE (2583) or TTY: 1-800-523-2847 and explain the

situation.

•Federal Civilians - Do not maintain as a family member on your policy:

- your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or

- your child over age 22 (unless they are disabled and incapable of self-support).

•TRICARE Eligibles - Do not maintain as a family member on your policy:

- Your child over age 21 if they are not enrolled in school (unless they are disabled or incapable of self-support)

- Your child over age 23 if they are enrolled in school (unless they are disabled or incapable of self-support)

If you have any questions about the eligibility of a dependent, please contact BENEFEDS.

Be sure to review Section 1, Eligibility, of this brochure, prior to submitting your enrollment or obtaining benefits.

Fraud or intentional misrepresentation of material fact is prohibited under the plan. You can be prosecuted for fraud

and your agency may take action against you if you falsify a claim to obtain FEDVIP benefits or try to obtain services

for someone who is not an eligible family member or who is no longer enrolled in the plan, or enroll in the plan when

you are no longer eligible.

28 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

Summary of Benefits

•Do not rely on this summary alone. This page summarizes specific expenses we cover; for more detail, please review the

individual sections of this brochure.

•We offer additional benefits for children age 13 and under as well as members with specific conditions (e.g., diabetes, hypertension)

see full details in Section 5.

•We offer an additional $50 frame allowance if you utilize a MyEyeDr. location.

•If you want to enroll or change your enrollment in this plan, please visit www.BENEFEDS.com or call 1-877-888-FEDS (3337),

TTY number 1-877-889-5680.

Covered Services In-Network

Vision Care Exams (a comprehensive exam that focuses on your eye health and overall wellness)

High Option: You pay nothing

Standard Option: You pay nothing

Page: 16

Standard Eyeglass Lenses (Contact lenses may be obtained in lieu of glasses)

High Option: You pay nothing.

Standard Option: You pay $10

Page: 16

Optional Lenses and Treatments

High Option: You pay nothing for Transitions®, Polycarbonate Lenses, Standard Progressives Lenses, Tinted Lenses, Ultraviolet

Protective Coating. Some additional copays apply to other lens treatments.

Standard Option: You pay nothing for Polycarbonate Lenses, Tinted Lenses, Ultraviolet Protective Coating. Some additional copays

apply to other lens treatments.

Page: 17

Frame Allowance - Collection Frames

High Option: You pay nothing

Standard Option: You pay nothing

Page: 17

Frame Allowance

High Option: You pay any amount over the $200 Plan allowance after a 20% discount. At MyEyeDr. you pay any amount over $250

frame allowance. 20% discount does not apply.

Standard Option: You pay any amount over the $140 Plan allowance after a 20% discount. At MyEyeDr. you pay any amount over

$190 frame allowance. 20% discount does not apply.

Page: 17

Contact Lenses

High Option: You pay any amount over the $150 Plan allowance after a 15% discount For Non-Specialty contact lenses the

Evaluation, Fitting and Follow-up care are covered in full at network providers. For Specialty lenses you receive a $60 allowance at

in-network providers.

Standard Option: You pay any amount over the $140 Plan allowance after a 15% discount

Page: 18

Laser Vision Correction

High Option: You pay the provider’s charge after the negotiated discount

Standard Option: You pay the provider’s charge after the negotiated discount

Page: 20

See Section 4, Your Cost for Covered Services, for the Out-of-Network benefits available under High Option. See Section 5, Vision

Services and Supplies for complete benefit information

29 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

Notes

30 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com

Rate Information

High - Bi-Weekly High - Monthly

Self Only Self Plus One Self and Family Self Only Self Plus One Self and Family

$5.63 $11.25 $16.88 $12.20 $24.38 $36.57

Standard - Bi-Weekly Standard - Monthly

Self Only Self Plus One Self and Family Self Only Self Plus One Self and Family

$3.53 $7.05 $10.58 $7.65 $15.28 $22.92

31 2024 Blue Cross Blue Shield FEP Vision® Enroll at www.BENEFEDS.com