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.

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.

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.

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 EST 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.

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 a Health Insurance Marketplace (Exchange) plan is not required.

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.  

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.

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.

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 does not meet the 130 hours per calendar month for 90 days.

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 (1-877-888-3337), 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 Aetna 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 plans' 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.

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.

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; i.e., you (or covered family members) cannot be covered by two FEDVIP dental plans or two FEDVIP vision plans.

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, 2023, through midnight EST 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; or
• an employee returning to service following a break in service of at least 31 days.
• 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.

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 (enrollee deployment), Yes (spouse deployment)
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

Qualifying Life Event: Returning to pay status from Leave without pay
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; and
• You cannot request a new enrollment based on a QLE before the QLE occurs, except for enrollment because of a 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 (benefedsportal@opm.gov) 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. 

FEDVIP enrollees can verify if they are paying their premiums on a pre- or post- tax basis by contacting BENEFEDS at 1-877-888-3337, TTY number 1-877-889-5680.

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;
• as sponsor or primary enrollee leaves active duty
• 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;
• are making direct premium payments to BENEFEDS and you stop making the payments;
• cancel the enrollment during Open Season;
• a Retired Reservist begins active duty; or
• the sponsor or primary enrollee leaves active duty.

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.

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

• Temporary Continuation of Coverage (TCC);
• spouse equity coverage; or
• right to convert to an individual policy (conversion policy).

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 reenrollment must meet the minimum contribution amount for the plan year. If you do not reenroll, 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. 

We will send you two identification (ID) cards when you initially enroll in Self, Self Plus One or Self and Family.  You should carry your ID Card with you at all times. You can print a temporary ID card online or call customer service at 1-855-347-6899 to verify your eligibility in the plan.

If you are enrolled in an FEHB plan, it is important to bring your FEHB identification card to every vision appointment because most FEHB plans offer some level of vision benefits separate from your FEDVIP coverage. Presenting both identification cards can ensure that you receive the maximum allowable benefit under each Program.

We list plan providers in the provider directory, which is updated nightly. The provider directory is on our website www.aetnafeds.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 Aetna Vision Preferred network is specific to routine vision care and is different from the network for the Aetna 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.

We negotiate rates with vision care providers and other health care providers to help save you money.  Aetna Vision Preferred in-network providers are contracted through EyeMed Vision Care. When scheduling an appointment, you should identify yourself as a member of the FEDVIP Aetna Vision Preferred plan. The provider is then responsible for verifying eligibility by contacting Aetna Vision Preferred either by telephone or via the web.  We refer to these providers as “In-Network providers”. If you use in-network providers to obtain covered care, benefits are paid at the in-network level. You are responsible for covered charges up to our negotiated plan allowance.

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 our network, we will reimburse you up to the maximum  reimbursement amount allowed by the plan. You are responsible to pay the out-of-network provider and then submit a claim to receive your reimbursement.

Pre-authorization is not required.

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

It is important to bring your FEDVIP and FEHB identification cards to every vision appointment because most FEHB plans offer some level of vision benefits separate from your FEDVIP coverage. Presenting both identification cards can ensure that you receive the maximum allowable benefit under each Program.

IF: You have medical coverage through FEHB and Aetna's FEDVIP vision plan
THEN: Present your FEHB ID card at the time of service as the FEHB plan will pay benefits first

IF: You have vision coverage through a non-FEHB plan and Aetna Vision coverage under FEDVIP (covered through a spouse)
THEN: Aetna Vision is the primary payor and your non-FEHB plan is secondary

IF: If your covered dependent child has coverage through a non-FEHB plan and Aetna Vision coverage under FEDVIP.
THEN: The parent's plan whose birthday occurs first in the calendar year (1. Month, 2. Date) is primary.  If the months and dates are the same for both parents, the primary payor is the plan that has provided coverage the longest.

Note: We do not coordinate benefits with non-FEHB health plans

If you live in an area with limited access to a network provider and you receive covered services from an out-of-network provider, we will pay the same benefit level as if you utilized the services of an in-network provider.  You are responsible for any difference between the amount billed and our payment.  Call us 1-855-347-6899, if you are having problems locating a provider in your area.

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: Exam
Standard Option We Pay: Up to $40
High Option We Pay: Up to $40

Services/Material: Single Vision Lenses
Standard Option We Pay: Up to $40
High Option We Pay: Up to $40

Services/Material: Bifocal Lenses
Standard Option We Pay: Up to $60
High Option We Pay: Up to $60

Services/Material: Trifocal Lenses
Standard Option We Pay: Up to $80
High Option We Pay: Up to $80

Services/Material: Lenticular Lenses
Standard Option We Pay: Up to $80
High Option We Pay: Up to $80

Services/Material: Contact Lenses
Standard Option We Pay: Up to $120
High Option We Pay: Up to $136

Services/Material: Medically Necessary Contact Lenses
Standard Option We Pay: Up to $210
High Option We Pay: Up to $210

Services/Material: Frames
Standard Option We Pay: Up to $80
High Option We Pay: Up to $150

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

Example: In the Aetna Vision High Option plan, you pay a $0 co-pay for an exam.

If you choose to visit a non-participating provider, you will be reimbursed according to the following fee schedule allowances shown in the chart below.  You are responsible for charges billed over the amounts shown.

Services/Material: Exam
Standard Option We Pay: Up to $40
High Option We Pay: Up to $40

Services/Material: Single Vision Lenses
Standard Option We Pay: Up to $40
High Option We Pay: Up to $40

Services/Material: Bifocal Lenses
Standard Option We Pay: Up to $60
High Option We Pay: Up to $60

Services/Material: Trifocal Lenses
Standard Option We Pay: Up to $80
High Option We Pay: Up to $80

Services/Material: Lenticular Lenses
Standard Option We Pay: Up to $80
High Option We Pay: Up to $80

Services/Material: Contact Lenses
Standard Option We Pay: Up to $120
High Option We Pay: Up to $136

Services/Material: Medically Necessary Contact Lenses
Standard Option We Pay: Up to $210
High Option We Pay: Up to $210

Services/Material: Frames
Standard Option We Pay: Up to $80
High Option We Pay: Up to $150

Please see Section 3, How You Obtain Care, for more information. 

Participating doctors provide a comprehensive exam that focuses on your eyes and overall wellness, including dilation as necessary.

Retinal Imaging

Up to $39

Up to $39

Lenses: covered in full (once every calendar year)

Standard Plastic single vision, lined bifocal, lined trifocal, and lenticular lenses

NOTE: You may choose prescription eyeglass lenses or contacts.

Nothing

$10

Lens Options (covered in addition to base lens): Standard Polycarbonate lenses (shatter-resistant)

Lens Options (covered in addition to base lens): Standard Scratch resistant coating

Lens Options (covered in addition to base lens): Standard Anti-reflective coatings

Premium Anti-reflective coatings tier 1

$32

$57 fixed discount **

Premium Anti-reflective coatings tier 2

$43

$68 fixed discount**

Premium Anti-reflective coatings tier 3

80% of retail price

80% of retail price

Lens Options (covered in addition to base lens): UV Protection and Tint (Solid or Gradient)

Lens Options (covered in addition to base lens): Photochromic lenses- lenses are clear indoors and darken outside

Lens Options (covered in addition to base lens): Standard progressive lenses

Nothing

Lens Options (covered in addition to base lens): Premium progressive lenses Tiers 1-3

Lens Options (covered in addition to base lens): Other premium progressive lenses

 80% of charge less $120 allowance + $20 copay

Frames -  once every calendar year

Any frame available at the provider location

Nothing for frames up to the $300 plan allowance

Frame Greater than $300: pay any amount after a 20% discount 

Nothing for frames up to the $160 plan allowance

Frame Greater than $160: pay any amount after a 20% discount  

Standard Contact Lens Fit & Follow-up (includes applications of clear, soft, spherical, daily-wear contact lenses for single-vision prescriptions) - once every calendar year 

.$40 fixed discount**

$40 fixed discount**

Premium Contact Lens Fit & Follow-up (Includes the application of toric (astigmatism .62D or higher in the contact lens), multifocal/monovision, post-surgical and gas permeable lenses. This includes extended/overnight wear for any prescription.) - once every calendar year 

90% of retail price

90% of retail price

Conventional/Disposable contact lenses

You may choose prescription eyeglass lenses or contacts once every calendar year

Nothing for Contact Lenses up to the $170 plan allowance

You will receive a 15% discount off the cost over $170 for conventional contact lenses

Nothing for Contact Lenses up to the $150 plan allowance

You will receive a 15% discount off the cost over $150 for conventional contact lenses

Medically necessary contact lenses

You may choose prescription eyeglass lenses or contacts once every calendar year

Contact lenses are medically necessary if you’re diagnosed with one of these conditions (ask your eye doctor for more info):

• Anisometropia of 3D in meridian powers
• High Ametropia exceeding – 10D or +10D in meridian powers
• Keratoconus when vision is not correctable to 20/30 in either or both eyes using standard spectacle lenses
• Vision improvement other than Keratoconus when vision can be corrected two lines of improvement on the visual acuity chart when compared to the best corrected standard spectacle lenses

Aetna Vision is a nationwide vision plan and therefore does not have network doctors overseas. To obtain services, visit any international eye care provider and you will be reimbursed out-of-network schedule: 

Services/Material: Exam
Standard Option We Pay: Up to $40
High Option We Pay: Up to $40

Services/Material: Single Vision Lenses
Standard Option We Pay: Up to $40
High Option We Pay: Up to $40

Services/Material: Bifocal Lenses
Standard Option We Pay: Up to $60
High Option We Pay: Up to $60

Services/Material: Trifocal Lenses
Standard Option We Pay: Up to $80
High Option We Pay: Up to $80

Services/Material: Lenticular Lenses
Standard Option We Pay: Up to $80
High Option We Pay: Up to $80

Services/Material: Contact Lenses
Standard Option We Pay: Up to $120
High Option We Pay: Up to $136

Services/Material: Medically Necessary Contact Lenses
Standard Option We Pay: Up to $210
High Option We Pay: Up to $210

Services/Material: Frames
Standard Option We Pay: Up to $80
High Option We Pay: Up to $150

We have several convenient ways to submit a claim for reimbursement.  You can download a claim form by going to www.aetnafeds.com, resources, claim forms and select Vision Claim form (for FEDVIP Aetna Vision Preferred Plan) and mail to the address on the form or go green and get paid faster by submitted electronically by accessing the online form.

Claim forms can be mailed to:

Aetna Vision
Attn: OON Claims, P.O. Box 8504, Mason, OH 45040-7111

When you visit a network doctor, you do not complete any paperwork or claim forms. Aetna Vision doctors verify your eligibility, plan coverage and obtain authorization from Aetna Vision.

If you decide not to see an Aetna Vision doctor, you are required to pay the provider in full at the time of your appointment and submit a claim for reimbursement up to the amount allowed by the plan.

You may obtain an out-of-network claim form for reimbursement by visiting our website, www.aetnafeds.com or calling our customer service at 1-855-347-6899. Please keep a copy of the information and mail the originals to:

• Aetna Vision
  Attn: OON Claims
  PO Box 8504
  Mason, OH 45040-7111

Out-of-network claims must be submitted to Aetna Vision within 15 months of the date of service for reimbursement.

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.

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

a) Write to us within 15 months from the date of our decision; and

b) Send your request to us at: Aetna Vision, Attention: Appeal Resolution Team, PO Box 14463, Lexington, KY 40512; and

Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and include copies of documents that support your claim, and explanation of benefits (EOB) forms. This is your first level appeal.

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

a) Pay the claim (or, if applicable, arrange for the vision provider to give you the care); or

b) Write to you and maintain our denial – go to step 3; or

c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of our request.

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, and the reason for the denial was based on medical necessity or for experimental or investigational reasons, you have the right to file a second level appeal. That appeal must be submitted within 60 days following the receipt of our first level denial.

4. If you do not agree with our final decision, and the amount of your claim is more than

$300 and the plan denied your claim because it did not consider the treatment a medical necessity, you may request an independent third party, mutually agreed upon by us and OPM, review the decision. You have 30 days from the date you received our final decision to request a third party review.

The decision of the independent third party is binding and is the final review of your claim. This decision is not subject to judicial review.

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

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).

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

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, under age 23 if they are a full-time student, or incapable of self-support because of a mental or physical incapacity.

Eye Exam –a comprehensive exam that focuses on your eyes and overall wellness.

Lenses – Standard Plastic single vision, lined bifocal, lined trifocal and lenticular lenses.

NOTE: Prescription Eyewear - Choose eyeglass lenses or contact lenses every calendar year. You cannot use both benefits within the same calendar year.

Lens options, including: Standard Polycarbonate lenses (shatter resistant)

Lens options, including: Standard Scratch resistant coating

Lens options, including: Standard Anti-reflective coating

Reimbursed up to $5

• Premium Anti-reflective coatings tier 1

$32

Reimbursed up to $5

• Premium Anti-reflective coatings tier 2

$43

Reimbursed up to $5

• Premium Anti-reflective coatings tier 3

80% of retail price

Reimbursed up to $5

Lens options, including: Tints

Lens options, including: UV protection

Lens options, including: Photochromic Lenses - lenses are clear indoors and darken outside

Lens options, including: Standard progressive lenses

Nothing

Lens options, including: Premium progressive lenses Tiers 1-3

$40-$65

Lens options, including: Other premium progressive lenses

80% of charge less $120 allowance + $20 copay

Conventional contact lenses –

NOTE: Contact Lenses, Choose eyeglass lenses or contact lenses every calendar year. You cannot use both benefits within the same calendar year.

Any amount over $170 plan allowance after a 15% discount

Reimbursed up to $136

Any amount over $170 plan allowance

Reimbursed up to $136

Reimbursed up to $210

Nothing for frames up to the $300 plan allowance

Frame Greater than $300:

pay any amount after a 20% discount

Reimbursed up to $150

Extra Discounts and Savings

Prescription glasses

• Minimum 20% savings on all non-covered lens options

•  Up to 40% discount off additional pairs of  prescription glasses and sunglasses; Up to 20% off non-prescription sunglasses

 Retinal imaging (also known as fundus photography) - When available at a participating provider’s office, members will pay no more than $39 for this service.

Laser vision correction

Members will receive a discount of 15% off retail or 5% off promotional prices at providers in the US Laser network. Or, members can save $800 and get a free LASIK exam at featured LasikPlus Vision Centers for a limited time. The LASIK discount is only available from U.S. Laser Network by calling 1-800-422-6600.

Replacement Contact Lens Program: Receive significant savings on replacement contact lens after your plan allowance has been exhausted by ordering online. Visit www.aetnavision.com for details.

Eye Exam - a comprehensive exam that focuses on your eyes and overall wellness.

Lenses - Standard Plastic single vision, lined bifocal, lined trifocal and lenticular lenses

NOTE: Prescription Eyewear - Choose eyeglass lenses or contact lenses every calendar year. You cannot use both benefits within the same calendar year.

Reimbursed up to:

Single Vision - $40

Lined bifocal - $60

Lined trifocal - $80

Lenticular - $80

Lens options, including: Standard Polycarbonate lenses (shatter-resistant)

Lens options, including: Standard Scratch-resistant coating

Lens options, including: Standard progressive lenses

Lens options, including: Premium progressive lenses Tiers 1-3

$95-$120

Lens options, including: Other premium progressive lenses

Lens options, including: Standard Anti-reflective coating

• Premium Anti-reflective coatings tier 1

$57 fixed discount *

Not covered

• Premium Anti-reflective coatings tier 2

$68 fixed discount *

Not covered

• Premium Anti-reflective coatings tier 3

80% of retail price

Not covered

Lens options, including: Photochromic Lenses - lenses are clear indoors and darken outside

Conventional contact lenses –

NOTE: Contact Lenses, Choose eyeglass
lenses or contact lenses every calendar year.
You cannot use both benefits within the same
calendar year.

Any amount over $150 plan allowance after a 15% discount

Reimbursed up to $120

Any amount over $150 plan allowance

Reimbursed up to $120

Reimbursed up to $210

Frame - Once every calendar year.  Any frame available at the provider location

Nothing for frames up to the $160 plan allowance

Frame Greater than $160:

pay any amount after a 20% discount

Reimbursed up to $80

Extra Discounts and Savings

Prescription glasses

• Minimum 20% savings on all non-covered lens options

•  Up to 40% discount off additional pairs of  prescription glasses and sunglasses; Up to 20% off non-prescription sunglasses

 Retinal imaging (also known as fundus photography) - When available at a participating provider’s office, members will pay no more than $39 for this service.

Laser vision correction

Members will receive a discount of 15% off  retail or 5% off promotional prices at providers in the US Laser network. Or, members can save $800 and get a free LASIK exam at featured LasikPlus Vision Centers for a limited time. The LASIK discount is only available from U.S. Laser Network by calling 1-800-422-6600.

Replacement Contact Lens Program: Receive significant savings on replacement contact lens after your plan allowance has been exhausted by ordering online. Visit www.aetnavision.com for details.