Call 1-800-877-7195 or visit VSP website www.vsp.com

The Prairie Band Potawatomi Nation is proud to provide a vision insurance plan that is available to each enrolled tribal member.

Participation Rules

• An eligible participant must be an enrolled member of the Prairie Band Potawatomi Nation.
• You may enroll at any time, however; your vision insurance will not take effect until the first day of the following month.
• The eligible participant must complete a vision insurance enrollment form. This form must be turned into the Member Services Department – located at the Government Center, Lower Level.
• Enrollment can be done over the phone as long as you have the necessary information for the person(s) being enrolled, to include: tribal enrollment number, date-of-birth, social security number, mailing address, daytime phone number, and emergency contact information.

Plan Design

VSP enrolled members will be entitled to a standard eye exam once every 12 months from the last date of service, spectacle lenses once every 12 months from the last date of service, and a frame once every 24 months from the last date of service. There is NO co-payment for tribal members enrolled under this plan.

Eye Exam

• Visual functioning: Tests check everything from visual clarity to eye focus and coordination.
• Eye component assessments: Important elements of the eye are analyzed, including the retina, optic nerve, cornea and lens.

Not only are these tests important for fitting eyewear but they can also allow for early detection and referral for diseases such as glaucoma or diabetes.

Eyewear

Frame: Members receive an allowance toward frames once every 24 months. VSP’s frame benefit fully covers more than half of the 42,000 frames currently available. Due to this large selection and the fact that buying habits and tastes differ from one region to the next, frame inventories may vary from office to office. When deciding on a frame, members should ask their doctors which ones are covered in full.

Lenses: VSP covers single vision, bifocal, trifocal or other more complex lenses when necessary for the patient’s visual welfare once every 12 months.

Contact Lenses: Contacts are covered in full up to $105.00 when medically necessary. If the patient chooses contact lenses for cosmetic reasons, professional services are discounted 15 percent and the plan pays an allowance for professional fees and materials every 12 months. Contact lenses are instead of complete pairs of prescription glasses.

Options: This plan is designed to cover the patient’s visual needs rather than cosmetic materials. If the patient selects any special features that are not medically necessary but sometimes chosen for cosmetic reasons, they will be responsible for the additional charge. Optional items may include (but are not limited to):

• Blended lenses
• Contact lenses (except as noted elsewhere)
• Oversize lenses
• Progressive (no-line) multi-focal lenses
• Photochromic or tinted lenses
• Coated or laminated lenses
• A frame that exceeds the plan allowance
• Certain limitations on low vision care
• Cosmetic lenses
• Optional cosmetic processes
• UV protected lenses

The following items will NOT be covered under the Plan:

• Orthopics or vision training and any associated supplemental testing
• Plano lenses
• Two pair of glasses in lieu of bifocals
• Lenses and frames furnished under this program, which are lost or broken, will not be replaced except at the normal intervals when services are otherwise available
• Medical or surgical treatment of the eyes
• Any eye examination, or any corrective eyewear, required by an employer as a condition of employment
• Corrective vision services, treatments, and materials of an exceptional nature

Procedures to Access VSP Services

1. When members are ready to use the plan, they simply call a VSP doctor. Members can call VSP at 1-800-877-7195 for help in finding a VSP participating doctor. They can also use the VSP website (www.vsp.com) to find a nearby doctor for general information about their vision coverage.
2. When making an appointment, the patient tells the doctor’s office that he or she is a VSP member, provides their identification number (Social Security number), and the name of the organization that has contracted with VSP for vision benefits (Prairie Band Potawatomi Nation). The doctor then obtains an authorization to provide services and materials from VSP.
3. At the appointment, the VSP doctor provides an eye exam and, if necessary, orders eyewear form a VSP contract laboratory. Tribal members do not have a co-payment. The patient will pay any additional costs resulting from cosmetic options or a non-covered service. VSP will pay the participating doctor directly for covered services and materials.
4. Services obtained through non-participating doctors are subject to the same limitations as services through VSP participating doctors. (The Prairie Band Potawatomi Nation will not be responsible for these claims. It is the member’s responsibility.)
   • If a member receives services from a non-participating doctor, they must pay the full amount of the bill.
   • Request a copy of the bill that shows a detailed list of the services received including amount of the eye examination, lens type and frame.
   • The itemized bill must be sent to VSP along with the member’s name and mailing address, social security number, and date of birth. This information must be mailed to Vision Service Plan, Attn: Non-Member Doctor Claims, P.O. Box 997105, Sacramento, CA 95899-7105.
   • Claims must be filed with VSP within 6 months after seeing the doctor.

If you have any questions or comments, please contact: Toll-Free 1-866-277-3722 or (785) 966-3910.