Introduction
When was the last time you had your eyes checked? Sometimes vision changes can be so subtle that we don’t even realize there’s been a change until we start having headaches or other signs of vision distress.
Vision Plan Options
The Vision Service Plan (VSP) covers you for an annual eye exam as well as for corrective lenses and frames or contact lenses. This plan allows you to see either a VSP eye care provider (and pay less) or a non-VSP eye care provider (at a higher cost to you).
The SafeGuard Premier Vision Plan is a prepaid vision plan. You select a SafeGuard vision care provider from the SafeGuard network at the time you need services. With SafeGuard, many services are covered at 100% and others require a copay. This plan also allows you to see a non-SafeGuard provider at a higher cost to you.
An “At-A-Glance” chart of your vision benefits is on the next page, followed by detailed information about the plans later in this Summary Plan Description (SPD).
Waive Cov erage Option
You may choose to waive Company vision coverage if you have vision coverage elsewhere or don’t need coverage for yourself and your family. You may waive coverage at the time you select benefits after meeting any waiting period, or during the annual open enrollment period.
Your
Vision Benefits At-A-Glance
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VSP |
SAFEGUARD |
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If You See a |
If You See a Non-VSP Provider |
If You See a SafeGuard Provider |
If You See a Non-SafeGuard Provider |
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Who Provides Care |
Your choice of VSP provider |
Any provider |
Your choice of SafeGuard provider |
Any provider |
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Copays |
You pay a $40 copay maximum ($15/eye exam and $25/materials). You are responsible for all amounts in excess of the covered expense for exams and materials |
You pay a $15 copay for standard vision care and services |
Plan pays $35 for an exam once every 12 months. You are responsible for all amounts in excess of the plan allowance. |
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Eye Examination |
Plan pays 100% of covered expenses for one eye exam every 12 months |
Plan pays up to $40 for one eye exam every 12 months |
Plan pays 100% for one eye exam every 12 months |
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Corrective Lenses |
Plan pays 100% of covered expenses for one pair of single vision, bifocal or trifocal lenses every 12 months |
Plan pays the following amounts for one pair every 12 months: n Single—up to $40 n Bifocal—up to $60 n Trifocal—up to $80 n Lenticular—up to $125 |
Plan pays 100% of covered expenses for one pair of single vision, bifocal or trifocal lenses every 12 months |
Plan pays the following amounts for one pair every 12 months: n Single—up to $25 n Bifocal—up to $35 n Trifocal—up to $45 n Lenticular—up to $55 |
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Frames |
Plan pays 100% of covered expenses every 24 months. You’re responsible for amounts in xcess of covered expenses for more expensive frames |
Plan pays up to $45 every 24 months |
Plan pays 100% of selected frames or issues a credit up to $40 towards an optional style once every 24 months |
Plan pays $55 every 24 months |
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Contact Lenses* Elective |
Plan pays 100% of covered expenses for one pair every 12 months Plan pays up to $105 for one pair every 12 months |
Plan pays up to $210 for one pair every 12 months Plan pays up to $105 for one pair every 12 months |
Plan pays for one pair every 24 months if prescription change so indicates |
Plan pays $25 every 24 months |
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Filing Claims |
You do not need to file any claims |
After you pay the non-VSP provider, you must submit an itemized bill and receipt of payment to VSP within six months |
You do not need to file any claims |
After you pay the non-SafeGuard provider, you must submit an itemized bill and receipt of payment to SafeGuard within six months |
*Contact lenses are covered in lieu of lenses and frames.
When
Coverage Begins
For Yourself
Your coverage will become effective on the first day of the month following your eligibility date, provided that you have returned a signed enrollment form within the first 31 days of your eligibility date (or on the first day of the calendar year following the annual open enrollment period). If you do not return your enrollment form within 31 days, your next chance to enroll for vision coverage will be during the annual open enrollment period in the fall, unless you have a qualified status change (see the About Your Benefits Program section in this binder for details).
If You’re Absent From Work
If you’re absent from work for any reason, including illness, disability or leaves of absence, you are considered to be an inactive employee. If you’re an inactive employee on the date coverage is scheduled to begin, your coverage will become effective on the first day of the month after you return to work. If you return to work on the first day of the month, then coverage will begin on that day.
For Your Dependents
Vision coverage for your dependents begins when your coverage begins, provided that you return a signed enrollment form within 31 days of your eligibility date. If you do not return your enrollment form within 31 days, your next chance to enroll your dependents for vision coverage will be during the annual open enrollment period in the fall.
If you get married, your new spouse and any eligible stepchildren are eligible for coverage the first of the month following your marriage date. You must enroll your new dependents within 31 days following the date of marriage.
You may also add your domestic partner and dependents of your domestic partner the first of the month following the completion and approval of the Affidavit of Domestic Partnership and the Family Status Change form available from Employee Benefits.
If you or your covered spouse/domestic partner have a baby, adopt a child, have a child placed for adoption or become the court-appointed legal guardian, you may enroll your new child within 31 days of the birth, adoption, placement for adoption or the date the court establishes legal guardianship.
About
the Vision Service Plan (VSP)
How the Plan Works
If You Use a Vision Service Plan (VSP) Provider
VSP providers have contracted with VSP to provide vision care services at special negotiated fees. You pay less when you see a VSP provider. Here’s how it works:
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Step 1 |
When you want to see a VSP eye care provider, call VSP at 1-800-877-7195 for a listing of VSP eye care providers in your area. If you already have a provider, ask the provider if he or she is a VSP provider. You can also find a directory of providers at www.vsp.com. |
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Step 2 |
Call the eye care provider to make an appointment. |
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Step 3 |
Tell your eye care provider that you’re a VSP member and an employee of Southern California Gas Company and provide your social security number. |
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Step 4 |
Your eye care provider will contact VSP to confirm your benefits before you go in for your appointment. |
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Step 5 |
After your exam, pay the provider any required copay(s) for the service(s) you received. |
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Step 6 |
You do not need to file a claim form—the VSP provider will file a claim for you. |
If You Use a Non-VSP Provider
The plan also provides benefits if you see a
non-VSP provider. Keep in mind, however, that you receive reduced benefits when
you see a non-VSP provider. Here’s how it works:
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Step 1 |
Make an appointment with any eye care provider of your choice. |
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Step 2 |
After you receive services and/or materials from the non-VSP provider, pay the provider directly. |
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Step 3 |
Send a copy of the itemized bill(s) and receipt of payment to VSP no later than six months following your date of service. The following must be included in your documentation: n Your name and mailing address n Your identification number (this is your Social Security Number) n The Company name (Southern California Gas Company) n Patient’s name, relationship to you and date of birth |
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Step 4 |
Send all required information to: Vision Service Plan |
What Is Cov ered
The following is a brief description of the services and supplies covered under VSP.
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Service or Supply |
Description |
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Eye examination |
You may receive one complete initial vision exam every 12 months from the last date of service. The exam includes an appropriate examination of visual functions and the prescription of corrective eyewear, if necessary. |
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Corrective lenses |
If you need corrective lenses, your eye care provider will order the proper lenses for you. You are responsible for elective extras, such as tinting or blending. You are eligible for this benefit once every calendar year. |
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Frames |
Your eye care provider will assist you in the selection of a frame, properly fit and adjust the frames, and provide subsequent adjustments (as necessary) to your frames. You are responsible for elective extras. You are eligible for this benefit every two years. |
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Contact lenses |
If you receive prior authorization for contact lenses, you may be covered for materials, an evaluation and fitting every 12 months. In order to receive the full benefit amount, your reason for getting contact lenses must be due to: n Cataract surgery n Extreme visual acuity problems that cannot be corrected with spectacle lenses n Certain conditions of Anisometropia n
Keratoconus When you choose contact lenses from an eye care provider for reasons other than the medically necessary reasons mentioned above, you will receive an allowance toward the cost of lenses selected for elective reasons (see “Your Benefit Amount” on page 7). |
Your Benefit Amount
Depending on whether you visit a VSP provider
or a non-VSP provider, you will receive the following benefits:
VSP Provider
If you receive services from a VSP provider, the plan will pay 100% of covered expenses after you pay a $15 copay for an eye exam and a $25 copay for materials—for a maximum copay of $40. Not all services or products are covered at 100%. Be sure to check with your provider.
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Service or Supply |
Maximum Benefit |
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Eye examination |
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Corrective lenses n Single Vision n Bifocal n Trifocal n
Lenticular |
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Frames |
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Contact lenses* Elective |
Plan pays up to $105 every 12 months. |
*Contact lenses are covered in lieu of lenses and frames.
Non-VSP Provider
If you choose a non-VSP provider, services and supplies will be covered according to the following schedule. After you pay a $15 copay for an eye exam and a $25 copay for materials, and the plan pays its maximum benefit, you are responsible for all additional charges.
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Service or Supply |
Maximum Benefit |
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Eye examination |
Plan pays up to $40 every 12 months. |
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Corrective lenses n Single Vision n Bifocal n Trifocal n
Lenticular |
Plan pays: n Up to $40 per pair every 12 months. n Up to $60 per pair every 12 months. n Up to $80 per pair every 12 months. n Up to $125 per pair every 12 months. |
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Frames |
Plan pays up to $45 every 24 months. |
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Contact lenses* Elective |
Plan pays up to $105 every 12 months. |
*Contact lenses are covered in lieu of lenses and frames.
What Is Not Cov ered
This plan is designed to cover your visual needs rather than elective materials.
If you choose any of the following extra items, the basic cost of the services
and/or supplies will be covered under the plan, and you will be responsible for
the balance of the cost:
n Blended lenses
n Contact lenses (except as previously noted)
n Oversized lenses
n Progressive multifocal lenses
n Photochromic or tinted lenses other than Pink 1 or 2
n Coated or laminated lenses
n A frame that exceeds the plan allowance
n Cosmetic lenses
n Optional cosmetic processes
n UV protected lenses
The following are not covered by the plan at all:
n Orthoptics or vision training and any associated supplemental testing
n
n Two pairs of glasses in lieu of bifocals
n Lenses and frames furnished under the plan which are lost or broken, except at the normal intervals when services are otherwise available
n Medical or surgical treatment of the eyes
n Any eye examination, or any corrective eyewear, required by an employer as a condition of employment
n Corrective vision services, treatments and materials of an experimental nature.
About
the Safeguard Premier Vision Plan
How the Plan Works
If You Use a SafeGuard Provider
SafeGuard providers have contracted with SafeGuard to provide
vision care services at special negotiated fees. You pay less when you see a
SafeGuard provider to receive benefits. Here’s how
it works:
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Step 1 |
When you need vision care, call SafeGuard at 1-800-428-8789 for a listing of SafeGuard providers in your area. You choose a SafeGuard provider from among those who are part of the SafeGuard network. Each member of your family may choose a different provider. Once you select a provider, all services (exams and materials) must be provided by that provider. |
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Step 2 |
Call the eye care provider to make an appointment. |
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Step 3 |
Your SafeGuard provider will either provide the necessary vision care or refer you to a specialist if necessary. |
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Step 4 |
After your exam, pay the provider any required copay(s) for the service(s) you received. |
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Step 5 |
You do not need to file a claim form—the SafeGuard provider will file a claim for you. |
If You Use a Non-SafeGuard Provider
The plan also provides benefits if you see a non-SafeGuard provider. Keep in mind, however, that you receive reduced benefits when you see a non-SafeGuard provider. Here’s how it works:
|
Step 1 |
Call SafeGuard (SafeHealth and Block Vision) at 1-800-428-8789 to request a claim form. |
|
Step 2 |
Make an appointment with any eye care provider of your choice. |
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Step 3 |
After you receive services and/or materials from the non-SafeGuard provider, pay the provider directly. Have the provider complete Section 2 of the claim form. |
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Step 4 |
Send the claim form and a copy of the itemized bill(s) and receipt of payment to SafeGuard no later than six months following your date of service. The following must be included in your documentation: n Your name and mailing address n Your identification number (this is your Social Security Number) n The Company name (Southern California Gas Company) n Patient’s name, relationship to you and date of birth |
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Step 5 |
Send all required information to: Block Vision Care |
What Is Cov ered
The following is a brief description of the services and supplies covered under SafeGuard.
|
Service or Supply |
Description |
|
Eye examination |
You may receive one complete initial vision exam every 12 months from the last date of service. The exam includes an appropriate examination of visual functions and the prescription of corrective eyewear, if necessary. |
|
Corrective lenses |
If you need corrective lenses, your eye care provider will order the proper lenses for you. You are responsible for elective extras, such as tinting or blending. You are eligible for this benefit every 12 months from your last date of service if there is a change in your prescription. |
|
Frames |
Your eye care provider will assist you in the selection of a frame, properly fit and adjust the frames, and provide subsequent adjustments (as necessary) to your frames. You are responsible for elective extras. You are eligible for this benefit every 24 months from your last date of service. |
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Contact lenses |