PROVIDER MANUAL
28120 U.S. Hwy. 281 N. u Suite 108 u San Antonio Texas 78260
800-662-8264, FAX 866-772-0285
www.EyetopiaPlans.com
FOR PROVIDER USE ONLY – DO NOT DUPLICATE WITHOUT PERMISSION
Updated: November 18, 2009
Table of Contents
Eyetopia Vision Care Overview 3
Eyetopia Contact Information 3
The Eyetopia Plan 4
Eyetopia Refractive Surgery Benefit 5
Frequently Asked Questions 7
Competitive Advantages and Disadvantages of Eyetopia Vision Plans 7
Eyetopia Member Referral Program 8
How to Ensure Reimbursement 8
Reimbursement Schedules (CF-35 & CF-40) 9
Maximizing Reimbursement 11
Contact list of our Strategic Vendors 12
Website Claim Submission—System Requirements and User Tips 13
Signing In 14
Looking Up a Patient 15
Viewing Patient Demographics 16
My Patient List 16
Verifying Patient Benefits/ Eligibility 17
Submitting a Claim 18
Claim Form - Required Fields 19
Claim Errors 20
Saved Claims 20
List of Current Employer Contracts with their Benefits 22
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Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264 u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Eyetopia Vision Care Overview
Eyetopia Vision Care offers Participating Providers more control and more responsibility in a wide area. It is important
that your staff understands the difference between Eyetopia and all the other vision plans that you accept. We
have listed five key differences that we feel make Eyetopia the perfect vision plan for every Texas eye care provider:
1) Eyetopia is a pre-paid discount plan, not an insurance company. This means all the rules governing insurance
plans do not govern Eyetopia.
 You will always get paid for covered services you render to a legitimate Eyetopia Member.
 Even if you forget to file the claim for 11 months, 30 days and 7 hours! (we have to cut off paying claims older
than a year, due to software and accounting limitations)
2) You can send your spectacle work to any lab you choose, or make them yourself 1
3) You can provide any contact lens brand you choose.
4) We contract with laser surgeons willing to accept discounts between $250.00 and $500.00 per eye and provide
a reimbursement for a portion of the post-op fees. So if you would like to co-manage Eyetopia Members
that take the refractive surgery option, you need to be sure you can co-manage with the designated Eyetopia
Vision Care surgeon in your area.
5) You get paid once per month. We batch all claims submitted before close of business on the last day of the
month. Checks go out by the 10th of each month.
 We only pay once per month because Eyetopia Providers are also Owners and are entitled to all the money
collected that month up to your Maximum Conversion Factor.2 We cannot pay claims until we have batched
all the claims submitted for that month.
 You have direct control over your Reimbursement Schedule in two ways:
 As a Provider you are also a Member Owner and can participate in governing the plan.
 Our Strategic Vendors have agreed to subsidize operating costs for their Member Owner customers.
Once you begin to see Vision Plan patients we are confident that you will agree with hundreds of other Eyetopia
Owners that this is as perfect a vision plan can get. We tell all prospective Clients (Employers) that our Participating
Providers love the plan and do everything possible to ensure that the Eyetopia Member has a positive experience
at their practice. We hope your experience with Eyetopia is so exceptional that you begin to recommend
it to your patients that complain about their vision insurance. 3
Eyetopia Contact Information
Customer Service:
830-438-6296, 800-662-8264, Fax 866-772-0285
Member@EyetopiaPlans.com
Monday through Friday – 8:30 AM to 5:00 PM
(Central Time)
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Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264 u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
1 See Page 12 for information on Eyetopia Strategic Vendors
2 See Page 9 for more information regarding Maximum Conversion Factors
3 See Page 8 for more information regarding our Owner’s Referral Program
The Eyetopia Plan
Eyetopia vision plans are essentially the same, regardless of the allowances or the eligibility periods they offer only two (2) benefits
for each Member in each eligibility period: An eye exam and the patient’s choice for vision correction. Once these two benefits
have been used, they are ineligible for either benefit regardless of their reason until the next eligibility period starts.
If a Provider discovers any medical condition during their eye examination, the eye exam should not be billed to Eyetopia, but to
their medical insurance. This will keep their Eyetopia vision exam benefit available for the remainder of their benefit period.
Eyetopia Gold offers medically necessary contact lenses and the contact lens exam for medically necessary contact lenses can be
billed to Eyetopia when no medical insurance is available. The frame, contact lens and surgery allowances, applicable co-pays
and eligibility periods are always printed on the back of every member’s card as shown below:
Example of Eyetopia 120/145 Membership Card
This example is showing the following information: The Member pays a $10.00 co-pay at the time of their exam. If they select
spectacles for their vision correction they can select frame with a $120.00 retail value or less and pay no additional fees. They
will pay a $20.00 materials co-pay upon ordering spectacle lenses or a $20.00 materials co-pay upon ordering contact lenses.
The contact lens allowance is $145.00, which includes the fitting fee and the cost of their contact lenses. All Eyetopia Vision
plans offer a per eye refractive surgery allowance that is shown on the card, $350.00/eye in this case.
Note 1: It is expected for you to charge your fitting fee to patients that may opt out of the contact lens benefit after an unsuccessful
trial period. You can either deduct it from their spectacle benefit, or have the patient pay you directly.
Note 2: The two numbers in the plan name always represent the plan allowances. The first number is for the frame ($120 allowance)
The second number is for the Contact Lenses ($145.00). If there is a third number it is probably representing the benefit
frequency (Eyetopia 120/145-24 for 24 month frame replacement frequency)
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Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264 u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Program Service Period
Program service periods are identified on-line. Please check their eligibility status on-line, do not rely on the date on Membership
Card. The card provides you with their unique identification number or you can use the employee’s Social Security number.
Services provided before the effective date and after the Expiration date are the responsibility of the Member and not the Plan.
The Member’s employer (the plan sponsor) maintain and submit a current list of their employees on the EyetopiaPlans.com website
on a weekly basis.
Member Name: John Doe
ID#: 10023123445 Effective Date: 10/01/09
Employer: ACME Plan: 120/145
Exam Co-pay: $10 Materials Co-pay: $10
Allowances:
Frame- $120 CL’s- $145 Surgery- $350
Customer Service Department: 1-800-662-8264
www.EyetopiaPlans.com
Participant is eligible for one (1) vision examination and one (1)
vision correction option during the eligibility period. The plan
provides three (3) options for vision correction; glasses, contact
lenses or refractive surgery.
Services are covered at participating provider locations only. Card
void when eligibility terminates.
For a complete listing of participating providers, visit our web-site,
www.eyetopiaplans.com.
Any changes in member’s status should be directed to the Eyetopia
Vision Care Customer Service Department.
28120 US Hwy 281 North, Suite 108 Ph: 1-800-662-8264
San Antonio, TX 78260 Fax: 1-866-722-0285
Eyetopia Refractive Surgery Benefit
Eyetopia offers an allowance toward all FDA approved refractive procedures performed by the Participating Provider.
Eyetopia was created to function with an integrated eye care delivery system operating through patient comanagement
between primary and tertiary eye care providers. Consequently, claims for refractive surgery are only
submitted by the post-operative eye care provider.
Eyetopia has an agreement with an area surgeon to be the exclusive surgeon for all area Eyetopia Members as long as
the surgeon provides all FDA approved procedures. If not, other providers are added to ensure all covered benefits
are available. The surgeon agrees to accept a discount per eye to become a Participating Provider. Primary eye care
providers (optometrists) need an established co-management relationship with the area surgeon(s) to be able to provide
Pre and Post-op care for Members selecting the refractive surgery option.
The Eyetopia Plan’s refractive surgery benefit has the following unique features:
1) We are committed to the integration of primary and tertiary care for refractive surgery. Allowing both professions to
practice in their fields of expertise and interest. Consequently, the primary care provider functions as a gatekeeper for the
refractive surgery benefit and tertiary care providers are accessed on a Referral Only basis. The RSC code identifies these
Primary Care Participating Providers on all Directory Listings and on the EyetopiaPlans.com website.
2) Pre-op Exams are performed by Primary Eye Care Providers and submitted to Eyetopia for reimbursement. Eyetopia
Members can change their mind and opt for contact lenses or spectacles after the additional testing is completed during
the free screening at Surgeon/Facility without losing any benefits.
3) We don’t offer a percentage discount; rather we offer a fixed dollar allowance. The standard Eyetopia plan provides
Members with a $350.00 discount allowance per eye and Eyetopia Gold provides a $500.00 discount allowance per eye.
Eyetopia reimburses a portion of the discount allowance to the provider of the post-operative care. (see example on next
page)
4) Eyetopia is the only plan offering a discount on all FDA approved procedures, however each surgeon can specify which
procedures they are willing to participate in.
5) Eyetopia offers exclusive agreements for Tertiary Care Participating Providers. Eyetopia offers no out of network benefits
so Eyetopia Members that prefer to consider an alternative surgeon would have to travel to another area of Texas to
receive their refractive surgery benefit.
6) Surgeons/Facilities do not have to submit claims for reimbursement. They just deduct an applicable portion from the standard
Post-op fees normally paid to the co-managing Optometrist. It is the Optometrist’s responsibility to file for the remaining
portion of their post-op fees to be reimbursed by Eyetopia.
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Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264 u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Example of Custom IntraLASIK OU procedures with Eyetopia Gold plan benefits ($500/eye):
Hypothetical Only – actual fees vary from surgeon to surgeon
Normal Co-Management
SERVICE U & C Fee Amount Paid Paid By: Paid To:
Global Fee Includes 1 Yr. follow-up: $4,400 $3,400 Patient Surgeon/Facility
Post-Op Fee from 1 Day to 1 Yr. $800 $550 Eyetopia Optometrist
Surgeon Portion $3,600 $3,400
Optometrist Portion $800 $550
Surgeon/Facility write-off $200
Optometrist Write-off $250
Eyetopia Co-Management
Using an Advertised Price: Eyetopia allows the patient an additional 10% discount from the advertised price
Eyetopia Co-Management
$1,000 off sale Advertised Amount Paid Paid By: Paid To:
Global Fee Includes 1 Yr. follow-up: $3,400 $3,060 Patient Surgeon/Facility
Post-Op Fee from 1 Day to 1 Yr. $600 $550 Eyetopia Optometrist
Surgeon Portion $2,800 $3,060
Optometrist Portion $600 $550
Surgeon/Facility write-off $540
Optometrist Write-off $250
Normal Co-Management
Example of Custom IntraLASIK OU procedures with Eyetopia 120/145 Plan Benefits ($350/eye):
Hypothetical Only – actual fees vary from surgeon to surgeon
Normal Co-Management
SERVICE U & C Fee Amount Paid Paid By: Paid To:
Global Fee Includes 1 Yr. follow-up: $4,400 $3,700 Patient Surgeon/Facility
Post-Op Fee from 1 Day to 1 Yr. $800 $350 Eyetopia Optometrist
Post-Op Fee from 1 Day to 1 Yr. $300 Surgeon/Facility Optometrist
Surgeon Portion $3,600 $3,400
Optometrist Portion $800 $650
Surgeon/Facility write-off $200
Optometrist Write-off $150
Eyetopia Co-Management
Using an Advertised Price: Eyetopia allows the patient an additional 10% discount from the advertised price
Eyetopia Co-Management
$1,000 off sale Advertised Amount Paid Paid By: Paid To:
Global Fee Includes 1 Yr. follow-up: $3,400 $3,030 Patient Surgeon/Facility
Post-Op Fee from 1 Day to 1 Yr. $600 $350 Eyetopia Optometrist
Post-Op Fee from 1 Day to 1 Yr. $300 Surgeon/Facility Optometrist
Surgeon Portion $2,800 $2,730
Optometrist Portion $600 $650
Surgeon/Facility write-off $870
Optometrist Write-off $150
Normal Co-Management
Page 6 of 28
Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264 u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Page 7 of 28
Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Frequently Asked Questions
Q: What does “Add-On” next to the polycarbonate and Hi-Index code mean?
A: ‘Add-On’ means you are paid an additional amount for the material upgrade. Always submit the lens code to receive
your full reimbursement.
Q: How do you handle patients that change their mind after having a Contact Lens Fitting?
A: You have two options. If they are staying in your practice and getting glasses you can add the cost of your fitting
fee to their frame cost. (I.E., Frame Allowance is $120, less $70 for fitting fee leaves $50 toward their frame purchase)
The other option would be to submit a claim for just the fitting fee. We’ll make a note in their file that allows
the patient to access any remaining balance later in the year or at another provider’s contact lens dispensary.
Q: When is it appropriate to ‘balance bill’ the patient?
A: You can always balance bill for amounts over allowances (Frames, Contact lenses & Refractive Surgery) and for
any extras not specifically listed. You can never balance bill for benefits associated with co-pays (Exams, Specctacle
Lenses, listed coatings and upgrades). Although contact lenses have a co-pay, because they also come with an allowance,
you can balance bill for any portion over the allowance.
Q: What is the definition of a ‘standard’ or ‘basic’ PAL?
A: More and more vision insurance plans are offering coverage on PAL lenses, but have graduated ‘co-pays’ depending
on the manufacturing costs involved. Eyetopia is attempting to keep things simpler and more flexible by allowing
each office to define their own ‘basic’ or ‘standard’ PAL lens. Remember that since you cannot balance bill for covered
lenses, you’ll need to select a ‘basic’ or ‘standard’ PAL that costs you around $45 per pair. Both the Signa-
Armorlite Navigator® lens or the Essilor Natural® lens fall into this price point.
Q: What spectacle lens materials and coatings are covered under the Gold plan?
A: We cover Polycarbonate or Hi-Index or CR-39 plastic. When making or ordering these lenses for a Gold plan
member, they should come with UV and Scratch coatings included.
Q: Are we reimbursed for the coatings covered by the Gold plan?
A: Not separately for Poly or Hi-Index lenses—the ‘Add-On’ reimbursement includes coverage for the coatings.
However, if you select CR-39 plastic for a Gold Member’s lenses, then you should bill for and be reimbursed for the
UV and Scratch coatings.
Q: What NPI number do I use when submitting claims through EyeSynergy?
A: Since this is a required field, you just enter tens zeros (0000000000) since EyeSynergy is not set up yet to accept
NPI numbers at this point in time.
Competitive Advantages and Disadvantages of Eyetopia Vision Plans
In general vision plans have focused on the glasses option and in almost all cases vision plans offer the best value on
their glasses option. Which is why Providers are usually discounted the most severely on reimbursements for this option.
Contact lenses have such a low profit margin that most plans reimburse the full allowance with little or no discount.
Virtually all vision plans are still just offering a discount for LASIK or PRK surgery. Eyetopia Vision Care
was created by providers for providers and consequently we have structured the plan to benefit providers more than to
benefit consumers. Provider/owners that are aware of the plan’s inherent weaknesses and strengths can greatly assist
us in maintaining a high satisfaction rate among Eyetopia Vision Plan Members.
Marketing Strengths Why?
¨ Higher than average frame and contact lens allowances. More closely matches expected retail costs. Improves general patient
satisfaction by lowering out of pocket costs..
¨ All refractive surgery options are covered. Allows providers to fit procedures to patients, better patient care.
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Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264 u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Eyetopia Member Referral Program
All Participating Providers are encouraged to market the individual Eyetopia plan to targeted patients.
· When employers change to a plan that a Provider isn’t participating in.
· Retiring patients that are losing their Employee benefits.
· Patients that take their prescriptions to look for a better price.
Participating Providers can earn a 2% commission when they refer an Employer that results in a sale even if an agent is involved
in the sale.
Please contact Sales at (800) 662-8264 ext. 101 or sales@eyetopiaplans.com for more information.
How To Ensure Reimbursement
Claims are paid on a monthly basis all clean claims submitted and accepted on or before the close of business on the last day of
business in the calendar month will be processed and paid by the 10th of the following month.
Claims can be submitted electronically through a link set up in the Provider Section of our website: www.EyetopiaPlans.com.
They are processed on a regular basis and rejected claims notices are sent out regularly as well. As long as a rejected claims are
corrected and resubmitted before the end of the month, they will be paid in the monthly batch. If you decide not to submit claims
online, you should mail or fax the HCFA to:
Eyetopia Vision Care
Claims Department
28120 U.S. Hwy. 281 N., Suite 108
San Antonio, TX 78260
Or Fax to 866-772-0285
Eyetopia has not yet set a filing deadline, as long as we can verify that the Member was eligible for services at the time of service,
the submitted claim will be paid. We have trouble verifying their eligibility when claims submission is beyond a year after
the date of service.
Reimbursement Schedules
The Eyetopia Provider Agreement ensures that the Participating Providers will get all the pre-paid vision plan payments paid after
deducting our operating expenses. All of the collected revenue is distributed to Participating Providers, nothing except an approved
reserve is retained in Eyetopia for any reason. The Provider Agreement also clearly states that Providers only get all the
pre-paid vision plan revenue. If an employer fails to pay and we are unsuccessful in recovering obligated funds, the Providers
have no recourse against Eyetopia or her assigns.
Marketing Strengths (continued) Why?
¨ Standard PAL Lens5 coverage More closely matches vision insurance competitors.
¨ Providers well established in the community Name recognition, provides a quality image.
¨ Most Providers are on most medical panels. Facilitates coordination of benefits, keeps the Eyetopia free to provide
materials benefits.
Marketing Weaknesses Why?
¨ No Out of Network benefits To prevent becoming an insurance company.
¨ Few discounts on add-ons, extras or 2nd pairs To protect our provider/owners profits.
¨ Fixed dollar Refractive Surgery benefit To protect our provider/owners profits.
¨ Few commercial optical panel members To protect the private practice of optometry.
If our marketing agent underestimates the costs involved in providing the contracted pre-paid vision services, the provider
has no recourse against anyone and is obligated by their agreement to provide the services promised for whatever
revenue is available. Eyetopia distributes the pre-paid vision care funds every calendar month. It is divided
among all the Participating Providers that make a claim for these funds in that month. Participating Providers
adopted an Adjusted Relative Value Units (ARVU) established by Medicare and the insurance industry to establish a
method of distributing these funds. The Eyetopia Marketing Committee established a fair market Conversion Factor
(CF) to allow us to calculate the cost of their pre-paid vision plan products. The Eyetopia Advisory Board declared
the formula, CF X ARVU, to be the “maximum” reimbursement to be distributed in any given calendar month. Any
surplus funds remaining would be rolled over into the next month and to maintain a reserve equal to two-months of
claims revenue. If at the end of the year there are still surplus funds, they will be distributed to all Participating Providers
proportionate to the ARVUs submitted during that calendar year.
(You will be paid the lower of either your U & C or the posted amount)
Lense reimbursements are "per pair" Potential * Panel
Description: ARVU CPT: $40.00 CF $35.00 CF
New Intermediate Exam 1.55000 92002 $62.00 $54.25
New Comprehensive Exam (S0620) 1.72000 92004 $68.80 $60.20
Established Intermediate Exam 1.31990 92012 $52.80 $46.20
Established Comprehensive Exam (S0621) 1.66000 92014 $66.40 $58.10
Medically Necessary Contact Lens Fitting 1.72000 92070 $68.80 $60.20
$100 Frame 2.02703 V2020 $81.08 $70.95
$120 Frame 2.43430 V2020 $97.37 $85.20
$130 Frame 2.63710 V2020 $105.48 $92.30
$150 Frame 2.97297 V2020 $118.92 $104.05
SV- Pl to 4 1.08108 V2100 $43.24 $37.84
SV- 4.12 to 7.00 1.16216 V2101 $46.49 $40.68
SV 7.12-20.00 1.35135 V2102 $54.05 $47.30
SV Pl-4.00/.12-2.00 1.08108 V2103 $43.24 $37.84
SV Pl-4.00/2.12-4.00 1.29730 V2104 $51.89 $45.41
SV Pl-4.00/4.25-6.00 1.48649 V2105 $59.46 $52.03
SV Pl-4.00/6.00 up 1.59459 V2106 $63.78 $55.81
SV 4.25-7.00/.12-2.00 1.24324 V2107 $49.73 $43.51
SV 4.25-7.00/2.12-4.00 1.43243 V2108 $57.30 $50.14
SV 4.25-7/4.25-6.00 1.56757 V2109 $62.70 $54.86
SV 4.25-7/6.00 up 1.62162 V2110 $64.86 $56.76
SV 7.25-12/.25-2.00 1.51351 V2111 $60.54 $52.97
SV 7.25-12/2.25-4 1.62162 V2112 $64.86 $56.76
SV 7.25-12/4.25-6 1.70270 V2113 $68.11 $59.59
SV 12 up/any cyl 1.75676 V2114 $70.27 $61.49
BF Pl-4.00 1.72973 V2200 $69.19 $60.54
BF 4.12-7.00 1.97297 V2201 $78.92 $69.05
BF 7.12-20.00 2.16216 V2202 $86.49 $75.68
BF Pl-4.00/.12-2.00 1.89189 V2203 $75.68 $66.22
BF Pl-4.00/2.12-4.00 2.02703 V2204 $81.08 $70.95
Page 9 of 28
Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Page 10 of 28
Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Lense reimbursements are "per pair" Potential * Panel
Description: ARVU CPT: $40.00 CF $35.00 CF
BF Pl-4.00/4.25-6.00 2.10811 V2205 $84.32 $73.78
BF Pl-4.00/6.00 up 2.16216 V2206 $86.49 $75.68
BF 4.25-7.00/.12-2.00 2.02703 V2207 $81.08 $70.95
BF 4.25-7.00/2.12-4.00 2.13514 V2208 $85.41 $74.73
BF 4.25-7.00/4.25-6.00 2.27027 V2209 $90.81 $79.46
BF 4.25-7.00/6.00 up 2.37838 V2210 $95.14 $83.24
BF 7.25-12/.25-2.00 2.16216 V2211 $86.49 $75.68
BF 7.25-12/2.25-4.00 2.29730 V2212 $91.89 $80.41
BF 7.25-12/4.25-6.00 2.37838 V2213 $95.14 $83.24
BF 12 up/any cyl 2.48649 V2214 $99.46 $87.03
Lenticular (Myodisc) Lenses 2.54057 V2215 $101.62 $88.92
TF Pl-4.00 2.29730 V2300 $91.89 $80.41
TF 4.12-7.00 2.38380 V2301 $95.35 $83.43
TF 7.12-20.00 2.56757 V2302 $102.70 $89.86
TF Pl-4.00/.12-2.00 2.29730 V2303 $91.89 $80.41
TF Pl-4.00/2.12-4.00 2.43243 V2304 $97.30 $85.14
TF Pl-4.00/4.25-6.00 2.62162 V2305 $104.86 $91.76
TF Pl-4.00/6.00 up 2.67568 V2306 $107.03 $93.65
TF 4.24-7.00/.12-2.00 2.37838 V2307 $95.14 $83.24
TF 4.25-7.00/2.12-4.00 2.51351 V2308 $100.54 $87.97
TF 4.25-7.00/4.25-6.00 2.67568 V2309 $107.03 $93.65
TF 4.25-7.00/6.00 up 2.75676 V2310 $110.27 $96.49
TF 7.25-12/.25-2.00 2.56757 V2311 $102.70 $89.86
TF 7.25-12/2.25-4.00 2.67568 V2312 $107.03 $93.65
TF 7.25-12/4.25-6.00 2.83784 V2313 $113.51 $99.32
TF 12 up/any cyl 2.96683 V2314 $118.67 $103.84
Progressive Lenses (Essilor Navigator®) 2.29730 V2781 $91.89 $80.41
POLY-TRIVEX ( Add on) 1.09371 V2784 $43.75 $38.28
Contact Lens Exam included in ccl pkg. 0.00000 92310 $0.00 $0.00
Contact Lens $125 3.50000 V2500-V2599 $125.00 $122.50
Contact Lens $135 3.78571 V2500-V2599 $135.00 $132.50
Contact Lens $145 4.07142 V2500-V2599 $145.00 $142.50
Contact Lens $200 5.64286 V2500-V2599 $200.00 $197.50
Contact Lens $250 7.07143 V2500-V2599 $250.00 $247.50
Medically Necessary Contact Lens 11.35714 V2531 (OD&OS) $400.00 $397.50
Prism 2.29730 V2715 $91.89 $80.41
UV Block Treatment 0.50000 V2755 $20.00 $17.50
Scratch Resistance Treatment 0.50000 V2760 $20.00 $17.50
Hi-Index Lens 1.54 to 1.65 (Add on) 1.49143 V2782 $59.66 $52.20
Hi-Index Lens >=1.66 (Add on) 1.68171 V2783 $67.27 $58.86
* “Billed To Others” Form Required to apply for CF-40 rates.
Page 11 of 28
Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264 u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Lense reimbursements are "per pair" Potential * Panel
Description: ARVU CPT: $40.00 CF $35.00 CF
Refractive Surgery Post Op Care-NuVision 5.00000 66999-NV-OD $200.00 $175.00
Refractive Surgery Post Op Care-NuVision 5.00000 66999-NV-OS $200.00 $175.00
Refractive Surgery Post Op Care-GMA 3.75000 66999-GMA-OD $150.00 $131.25
Refractive Surgery Post Op Care-GMA 3.75000 66999-GMA-OS $150.00 $131.25
Refractive Surgery Post Op Care-UGMA $350 7.85714 66999-UGMA-OD $314.29 $275.00
Refractive Surgery Post Op Care-UGMA $350 7.85714 66999-UGMA-OS $314.29 $275.00
Refractive Surgery Post Op Care-UGMA $500 7.85714 66999-UGMA-OD $314.29 $275.00
Refractive Surgery Post Op Care-UGMA $500 7.85714 66999-UGMA-OS $314.29 $275.00
* “Billed To Others” Form Required to apply for CF-40 rates.
Maximizing Reimbursement
Two reimbursement schedules have been adopted and are referred to as (CF-40) and (CF-35). Eyetopia Vision Plans keep Membership
Fees competitive while offering the highest vision plan reimbursement schedule in Texas through the financial support of
strategic vendors. All Eyetopia Providers have executed a Strategic Vendor Acceptance Form that allows Eyetopia to collect rebates
on their purchases from these strategic vendors. A Provider who sends all their “shipped to sales” to an ELOA lab and buys
$36,000 in annually from strategic frame vendors.
Eyetopia uses the vendor rebates to defray operating expenses and passes these savings on to all Members. The goal of Eyetopia
is to keep Panel Member (CF-35) reimbursements competitive while continuing to maximize supporting Member reimbursements.
The following comparison was made during our 2006 Annual Meeting held on March 25th, 2006. This illustrates the advantages
of member support of a provider owned vision plan.
Reimbursement Comparison to Medicare and VSP®4
Description: CPT: $40.00 CF $35.00 CF MEDICARE VSP
New Intermediate Exam 92002 $62.00 $54.25 $50.41 $67.50
Frame for Plan 120/145 V2020 $97.37 $85.20 N/A $37.50
SV- 4.12 to 7.00 V2101 $46.49 $40.68 $44.13 $32.50
BF Pl-4.00 V2200 $69.19 $60.54 $47.49 $43.00 *
TF Pl-4.00 V2300 $91.89 $80.41 $62.01 $53.00
Progressive Lenses V2781 $91.89 $80.41 N/A $80.00
Contact Lens Plan 120/145 V2500-V2599 $145.00 $142.50 $101.26 Plan Dependent
UV Lenses V2755 $20.00 $17.50 $17.76 N/A
AR Coat V2750 $49.14 $43.00 $20.41 $17 to $20
Scratch Resistant coating V2760 $20.00 $17.50 $14.23 $8.00
Polycarbonate lenses V2784 $40.00 $38.28 $38.28 $13 to $15
Hi-Index Lens 1.54 to 1.65 V2782 $59.66 $52.20 $52.20 $20.00
Hi-Index Lens >= 1.66 V2783 $67.27 $58.86 $58.86 $33.00
* This is a dispense fee only, VSP® pays all manufacturing costs.
If you would like to suggest changes to either of our two reimbursement schedules, please contact us and we will get you in touch
with a member of the Eyetopia Marketing Committee. The Marketing Committee is responsible for keeping our Membership
Fees competitive throughout Texas.
4 This comparison was done in 2006 and was only an estimate based on information provided to the Marketing Committee and may not be current
or be applicable to all areas in Texas.
Page 12 of 28
Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264 u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Contact List of Our Strategic Vendors
Company Contact Area Phone Fax Email
Essilor Bruce Winslow National 800-638-957 x6537 407-628-4996 bruce.winslow@eloa.com
(ELOA) Denny Geuder Director– Strategic
Alliances
336-420-9795 dgeuder@essilorusa.com
Patrick Higuera District Manager 209-607-5141 (cell) phiguera@essilorusa.com
Melanie Aguilera IPA Service Rep 214-496-4000 x4318 maguilera@essilorusa.com
Debbie Reim Dallas dreim@essilorusa.com
Patrick Shiller Fort Worth pshiller@essilorusa.com
Jeremy Grandstaff East TX jgrandstaff@essilorusa.com
Bruce Tetreault Houston bruce.tetreault@eloa.com
Lynda Summers Houston lsummers@essilorusa.com
Billy Chambers South TX 210-240-1970 (cell) billy.chambers@eloa.com
Bette Hilb Central/West TX. 325-212-8195 (cell) 325-949-4161 bhilb@essilorusa.com
Clear Analiza LiganViri Corporate aliganviri@cvoptical.com
Vision Mark McCann Regional Mgr. 800-228-6329 markmccann@cvoptical.com
Optical Sherrilyn Miele South TX 512-627-7786 smiele@cvoptical.net
Mel Burkhart Central TX 972-816-5879 Sharme42@aol.com
Diane Glover Houston 832-326-0982 dg77381@hotmail.com
Monty Smith Dallas/East TX 972-754-9419 montyj328@yahoo.com
Bud Witte West TX. 505-362-0896 budwitte@msn.com
Safilo USA Pat Koran Texas 405-751-0952 973-240-4820 pkoran@repmail.safilousa.com
Linda Bobo South TX.
Pedro Reh South TX. pedro_reh@hotmail.com
Larry Taylor South TX. ldttaylor@aol.com
Michelle McBride Corporate 800-631-1188 x4952 michellemc@safilousa.com
Chuck Winkle South TX. chwnk@aol.com
Signature Michael Price CEO 800-765-3937 310-330-2765
Eyewear Dana Michalke National 800-765-3937 x6024 310-330-2765 dmichalke@signatureeyewear.com
Kevin Seifert VP Operations 800-765-3937 310-330-2765 kseifert@sigeye.com
Mitch Whitaker Regional Mgr. 800-765-3937 310-330-2765 mwhitaker@signatureeyewear.com
Renee Edelstein Cindy Keeney’s Director
of Ops.
800-765-3937 x6625 310-330-2765 redelstein@sigeye.com
Judy Framan El Paso 800-765-3937 x6020 310-330-2765 jframan@sigeye.com
Franklin Duncan Houston 800-765-3937 310-330-2765 fduncan@sigeye.com
Debbie McCollough Houston 800-765-3937 310-330-2765 dmccollough@sigeye.com
Gregg Daniels Austin, DFW 800-765-3937 x6018 310-330-2765 gdaniel@sigeye.com
Cynthia Keeney Austin/South TX 210-326-0110 (cell) 210-402-0656 ckeeney@sigeye.com
Vision Marilyn McCluskey
West Eye Cheryl Poirrier Texas 800-640-9485 x153 757-546-1346 cpoirrier@vweye.com
VEATCH Staff National 800-447-7511 order@veatchinstruments.com
System Requirements and User Tips
The following guidelines will ensure successful use of eyeSynergy®.
System Requirements
Minimum Hardware Configuration Recommended Hardware Configuration
1024 x 768 screen resolution
15 inch monitor
256 color video mode
Pentium 350 or better
64MB RAM
800 x 600 or 1024 x 768 screen resolution
17 inch monitor
256 color video mode
Pentium lll or better
128MB RAM
Recommended Software Configuration
Internet Explorer 5.0 or later
Recommended Internet Configuration
Disable pop-up blockers & enable Javascript in Internet
Explorer
Adobe Acrobat Reader 7.0 or later
Disable “Reuse windows for launching shortcuts” in
Internet Explorer.
User Tips
·      Avoid using the “Back” button on your browser. Use the provided buttons and links to navigate throughout
eyeSynergy®.
·      Avoid using the “Enter” key on your keyboard. Use the provided buttons to process information.
·      Required fields are light green in color and marked with a red asterisk.
Website Claims Submission
Registration
Before logging onto eyeSynergy® for the first time, providers must call the Customer Service Department at
(800) 662-8264 to obtain a User ID and password. Once registration is successfully completed, the user name for
the account will become the 9-digit tax ID number provided during the registration process. The user name does
not include dashes, parenthesis or spaces.
Password
The default password for newly registered accounts will be provided to you upon registration. Please note that the
password is case sensitive. You may change your password for the account when signing in for the first time by
following the steps provided.
Need assistance?
For assistance with registration, please contact us toll-free at (800) 662-8264, ext. 112.
Page 13 of 28
Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264 u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Figure 1. Claims & Eligibility
Website Claims Submission
Figure 2. eyeSynergy® Sign In
Signing In
1. Access eyeSynergy® via our website at www.eyetopiaplans.com by clicking the Providers link and then click-
ing the Claims & Eligibility button. [Figure 1]
·      You may also type the following address into your web browser to access the eyeSynergy® home page:
https://www.eyeSynergy.com/ES_TEG.
2. Enter your User Name and Password in the fields located on the right-hand side of the page.
Click the button to log on. [Figure 2]
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Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264 u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Website Claims Submission
Looking up a Patient
1. Click the button in the Current Patient Box located at the top of the page.
2. Enter the patient’s Last Name and Date of Birth. The First Name field is optional. [Figure 3]
Figure 3: Looking up a New Patient
3. Click the button to view your search results. [Figure 4]
Figure 4: Search Results
4. Click the button located to the left of the patient for which you are searching. This will add the patient
to the Current Patient Box located at the top of the page. Clicking will also add the patient to My Pa-
tient List for future reference. Please refer to page 6 for additional information about My Patient List.
OR
Look up an Existing Patient from My Patient List
1. From the main menu bar, click Patient.
2. From the Patient drop-down menu, select My Patient List to view your patient list.
3. Click the button located next to the patient you would like to change your Current Patient to. This will
add the patient to the Current Patient Box located at the top of the page.
Important!
Current Patient in the box must be changed prior to reviewing eligibility or benefits and/or submitting a claim for
a new patient. Also always verify the Current Patient accurately reflects the patient for whom you intend to re-
view eligibility or benefits and/or submit a claim.
Page 15 of 28
Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264 u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Website Claims Submission
Viewing Patient Demographics/Plan Information
Patient demographics and plan information such as health plan (ie: Uvalde CISD), plan type
(ie: 120/145) and effective date are available online. [Figure 5]
Figure 5: Patient Demographics
1. Ensure the patient for whom you would like to view demographics/plan information is displayed in the Current
Patient Box located at the top of the page.
2. From the Patient drop-down menu, select Current Patient to view your current patient’s demographic/plan in-
formation.
My Patient List
My Patient List is an accumulation of patients selected in eyeSynergy® by your office. My Patient List includes es-
sential patient information such as patient ID, address and DOB. Patients are automatically added to My Patient
List upon each successful search and selection of a patient.
Access My Patient List
1. From the main menu bar, click Patient.
2. From the Patient drop-down menu, select My Patient List to view your Patient List. [Figure 6]
Figure 6: My Patient List
Page 16 of 28
Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264 u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Website Claims Submission
Remove Patients from My Patient List
Patients will remain on My Patient List until they are removed. Removing patients from my patient list will not
have an adverse affect on eligibility or claims and may be added back to My Patient List at any time.
1. With My Patient List displayed, locate the patient you would like to delete from My Patient List.
2. Click the button next to the patient you would like to delete.
3. You may sort My Patient List by any column displaying a button.
Verifying Patient Benefits/ Eligibility
All members are eligible for services once every twelve (12) months from their effective date. When viewing
member eligibility, it is important to review the following fields: Eye Exam, Vision Correction, Effective Date and
Current Status.
1. Ensure the patient you would like to confirm benefits for is displayed in the Current Patient Box located at the
top of the page.
2. From the main menu bar, click Patient and then click Current Patient.
3. This will display the summary information for the Current Patient.
4. Health Plan will determine the member’s EMPLOYER (see Contract Benefits sheet at the back of this manual.)
5. Plan Type will determine the level of coverage (see attached Contract Benefits sheet)
Each member’s plan renews on her/his respective Effective Date. Based on the dates, if any, in the Last Eye
Exam and Last Vision Correction (glasses OR contact lenses OR refractive surgery) fields, eligibility can be deter-
mined. If any corresponding date is LESS then twelve (12) months prior to their Effective Date, the member is
not eligible for those services until their renewal date. If there is NO date in the Last Eye Exam and/or Last Vi-
sion Correction fields, we assume the member is eligible; however, you may contact us to verify her/his eligibility.
Note
If the member TERMINATED her/his plan, you will NOT be able to find her/him on eyeSynergy® website. Please
call us at (800) 662-8264 for the terminated member’s eligibility.
Example
Benefit plan for Current Patient in Figure 7 (ID# 123456789) allows both an eye examination and a vision correc-
tion every 12 months from the effective date. Figure 7 shows his last exam date was on 09/10/2008. This makes
him eligible for his next eye examination on or after 09/01/2009*. For materials, he used the benefit on
05/19/2007; thus making him eligible for new materials until or after 09/01/2009*.
Page 17 of 28
Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Website Claims Submission
Figure 7: Benefit Summary
* Patient’s may be eligible for services prior to benefit renewal under certain circumstances. Please refer to the Provider Refer-
ence Guide or contact us at (800) 662-8264 for additional information.
Submitting a Claim
1. Ensure the patient you would like to submit a claim for is displayed in the Current Patient Box located at the
top of the page.
2. From the Main Menu Bar, click Providers.
3. From the Providers drop-down menu, click Submit a Claim to open the claim form. [Figure 8]
Figure 8: Minimized Claim Form
4. Complete the required fields outlined on the following pages.
5. Once all required fields are complete, the claim is ready for submission. Click the button located at
the bottom of the page.
6. A pop-up window citing terms and conditions of online claim submission will appear. Click the OK button once
you have reviewed and agree to the terms and conditions.
7. A claim ID number will be provided once the claim is submitted successfully. Click the button to view or
print a copy of the submitted claim.
Page 18 of 28
Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Website Claims Submission
Note
A minimized version of the claim form is initially displayed. The minimized form contains commonly used fields in
addition to all required fields. To display all available fields, click the Maximize link located on top of the claim
form on the right hand side.
Claim Form - Required Fields
Page 19 of 28
Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Website Claims Submission
Claim Errors
To avoid errors during claim submission, ensure that all required fields are populated prior to submission. Please
note that required fields are light green in color and marked with a red asterisk. If present, errors will be identi-
fied after the terms and conditions of online claim submission are accepted. Errors will be summarized at the bot-
tom of the claim form and will also be outlined in red where the error exists on the form. Once errors are re-
solved, click the button to try again. Receipt of a claim ID number will confirm successful submission of
the claim.
Need assistance?
For assistance with resolving claim errors, please contact us toll-free at (800) 662-8264.
Saved Claims
Incomplete claims may be saved at any time during the claim submission process and later retrieved for comple-
tion, deletion and/or submission. Saved claims will be stored online until they are submitted or deleted.
Saving a Claim
1. While on the claim form, click the button located at the bottom of the claim form.
2. A pop-up window including the claim ID number for your saved claim will appear. Click the OK button to
return to My Patient List.
Viewing Saved Claims
1. From the main menu bar, click Providers.
2. From the Providers drop-down menu, click Saved Claims to view your saved claims. [Figure 9]
Figure 9: Saved Claims
Page 20 of 28
Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Website Claims Submission
Deleting a Saved Claim
1. With Saved Claims displayed, locate the claim you would like to delete.
2. Click the Delete link next to the claim you would like to delete. Once clicked, the claim is deleted.
NOTE
Saved claims will remain online until they are submitted or deleted.
Completing a Saved Claim
1. With Saved Claims displayed, locate the claim to be completed.
2. Click the Edit link next to the claim to be completed. This will bring up the original claim and any remain-
ing required fields may be completed at this time.
3. Once all required fields are complete, the claim is ready for submission. Click the button located
at the bottom of the page.
4. A pop-up window citing terms and conditions of online claim submission will appear. Click the OK button
once you have reviewed and agree to the terms and conditions.
5. A claim ID number will be provided once the claim is submitted successfully. Click View Claim to view or
print a copy of the submitted claim or click OK to return to My Patient List.
Page 21 of 28
Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Website Claims Submission
Contract Benefits Grid (Listed Alphabetically)
The following grid shows each contract and what their corresponding plan benefits are. Based on the Contract
ID field, providers can determine benefit allowances and co-pays for each patient.
Page 22 of 28
Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Employer Plan
Exam
Copay
Material
Copay Covered Lens Materials
Frame
Allow
CL’s Allow
RS Allow
Ag Nutrition
Trucking
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted- $65.
APEX
Collision
Ctr.
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted- $65.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Bandera
ISD
130/145 $10 $10 Non-coated CR-39 plastic SV, BF, TF, or PAL $130 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65
150/250 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $250/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Boerne ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Brady ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65
150/250 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $250/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Central
Plains
Center for
MHMR
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65
150/250 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $250/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
City of
Del Rio
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
City of
Eagle Pass
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65.
150/250 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $250/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
City of
Penitas
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65.
150/250 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $250/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Website Claims Submission
Page 23 of 28
Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Employer Plan
Exam
Copay
Material
Copay Covered Lens Materials
Frame
Allow
CL’s Allow
RS Allow
City of
Pleasanton
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF $120 $145/$400 $350/eye
PAL is extra base lens paid at V2303 rate.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included
Connally
Memorial
Medical
Center
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Crystal City
ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
D’Hanis ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF $120 $145/$400 $350/eye
PAL is extra base lens paid at V2303 rate.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included
Devine ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Edcouch-
Elsa ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF $120 $145/$400 $350/eye
PAL is extra base lens paid at V2303 rate.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Edinburg
CISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Education
Service
Center
(Region 1)
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted- $65
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Floresville
ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted- $65
150/250 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $250/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Flour Bluff ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted- $65.
150/250 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $250/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Website Claims Submission
Page 24 of 28
Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Employer Plan
Exam
Copay
Material
Copay Covered Lens Materials
Frame
Allow
CL’s Allow
RS Allow
Focal Point
Vision
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF $120 $145/$400 $350/eye
PAL is extra base lens paid at V2303 rate.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included.
Fort Sam
Houston
ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted- $65.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Friends &
Family
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
High Plains
Surgery Ctr.
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65.
Howard
Payne
University
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL $120 $145/$400 $75/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65.
150/250 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $250/$400 $125/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Individual
Plans
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted- $65.
150/250 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $250/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
I.R.R.A.
Charter
School
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
KIPP Aspire 120/145 $10 $20 Non-coated CR-39 plastic SV, BF, or TF. $120 $145/$400 $350/eye
Academy PAL is extra base lens paid at V2303 rate.
Knippa ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted- $65.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
La Feria
ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted- $65
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
La Pryor
ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
La Villa ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65.
Website Claims Submission
Page 25 of 28
Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Employer Plan
Exam
Copay
Material
Copay Covered Lens Materials
Frame
Allow
CL’s Allow
RS Allow
La Villa ISD 150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
(Cont’d) Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Lasara ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65.
Lubbock ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Lyssy & Eckel
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF $120 $145/$400 $350/eye
PAL is extra base lens paid at V2303 rate.
Lytle ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Manor ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted- $65.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Mercedes ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Monte Alto
ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Motley
County ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted- $65.
150/250 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $250/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Navarro ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted- $65.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF $120 $145/$400 $250/eye
PAL is extra base lens paid at V2303 rate.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included
Nederland
ISD
Website Claims Submission
Page 26 of 28
Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Employer Plan
Exam
Copay
Material
Copay Covered Lens Materials
Frame
Allow
CL’s Allow
RS Allow
New
Braunfels
Christian
Academy
100/135 $10 $10 Non-coated CR-39 plastic SV, BF, TF $100 $135 /$400 $250/eye
PAL is extra base lens paid at V2303 rate.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included
Plainview
Country Club
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted- $65.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Plainview
ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Plainview
Surgical
Care
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted- $65.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Randolph
Field ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Roma ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65
150/250 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $250/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Sabinal ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF $120 $145/$400 $350/eye
PAL is extra base lens paid at V2303 rate.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included.
San Antonio
Area
Foundation
100/125 $10 $20 Non-coated CR-39 plastic SV, BF, TF $100 $125/$400 $250/eye
PAL is extra base lens paid at V2303 rate.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
San Benito
CISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
San Felipe
Del Rio CISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF $120 $145/$400 $350/eye
PAL is extra base lens paid at V2303 rate.
San Marcos
CISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65.
150/250 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $250/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Website Claims Submission
Page 27 of 28
Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Employer Plan
Exam
Copay
Material
Copay Covered Lens Materials
Frame
Allow
CL’s Allow
RS Allow
San Perlita
ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65/
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
South Side
ISD
120/145 $ - $ - Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45
150/250 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $250/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
South Texas
Education
Technology
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65.
150/250 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $250/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Taylor ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65.
150/250 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $250/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Thorndale
ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65.
150/250 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $250/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
TLC
Academy
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65.
150/250 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $250/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Ultrafryer
Systems
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
United Day
School
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF $120 $145/$400 $250/eye
PAL is extra base lens paid at V2303 rate.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included
United ISD
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF. $120 $145/$400 $350/eye
PAL is extra base lens paid at V2303 rate.
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included
Website Claims Submission
Page 28 of 28
Provider Relations: 28120 U.S. Hwy. 281 N., Suite 108 u San Antonio, Texas 78260
800-662-8264u 830-438-6296 u Fax: 830-438-6221 u www.EyetopiaPlans.com
Employer Plan
Exam
Copay
Material
Copay Covered Lens Materials
Frame
Allow
CL’s Allow
RS Allow
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65.
120/125-24 $10 $20 Non-coated CR-39 plastic SV, BF or TF $120 $125/$250 $250/eye
Frames are every 24 months.
Basic Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, PAL Upgrade- $45, Anti-Reflective- $45.
150/250 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $250/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Uvalde
Memorial
Hospital
120/145 $10 $20 Non-coated CR-39 plastic SV, BF, TF, or PAL. $120 $145/$400 $350/eye
Lens Add-ons: UV Coat & Tints- $12, Scratch Coat- $15, Poly Upgrade- $35, Anti-Reflective- $45, Warranted AR- $65
150/200 $5 $ - High Index or Poly for SV, BF, TF, or PAL $150 $200/$400 $500/eye
Lens Add-ons: UV & Scratch Coats included, Tints- $12, Standard AR- $45, Warranted AR- $65
Uvalde
CISD
 davido.extraxim@gmail.com