The PAISBOA Health Benefit Trust is happy to offer all of its members who are on the medical plan a Vision
Benefit through VBA. Everyone on the plan will be eligible for an annual vision screening with their
optometrist for a $25 copay. Everyone will also have a lenses and hardware allowance, outlined below.
VBA #4675
Effective 11/1/19
$25 Exam /$0 Materials Copay
FREQUENCY OF SERVICE: Last Date of Service DEPENDENT AGE: 26
Employee Spouse Children
Vision Exam 12 Months 12 Months 12 Months
Lenses 12 Months 12 Months 12 Months
Frames 24 Months 24 Months 24 Months
BENEFITS: Employee can select either:
VBA Participating Provider
Amount Covered/Benefit
Non-Participating
Provider
Amount Reimbursed
(Less Copayment)F (Zero Copayment)
Vision Exam (Glasses or Contacts) 100% $45
Clear Standard Lenses (Pair):
Single Vision 100% $40
Bifocal 100% $60
Blended Bifocal 100% $60
Trifocal 100% $80
Progressives C Controlled CostD $80
Lenticular 100% $120
Polycarbonate 100% N/A
Scratch Coat-1 Yr 100% N/A
Transitions incl. Solid or Gradient Lens Tint 100% N/A
Frame B 100% $70
-OR-
Elective Contacts (in lieu of eyeglass benefits)
Material Allowance $100 $100
Fitting Fee 15% off UCRA N/A
-OR-
Medically Necessary ContactsE 100% $450
Low Vision Aids (Per 24 Months. No Lifetime Max) $650 $650
-AND-
Lasik Surgery (once every 8 years) N/A $250
A Usual, Customary, and Reasonable.
B Within the program’s $40 wholesale allowance (approximately $100 to $120 retail).
C Progressive lenses typically retail from $150 to $400, depending on lens options. VBA’s controlled costs generally range from $45 to
$188.
D Unless otherwise prohibited by law.
E Medically Required Contacts may only be selected in lieu of all other material benefits listed herein.
F A $25 copayment is applied to the vision exam from a VBA Member Doctor only.