Medical & Dental
How-to: Finding a POMCO Dentist
Medical Claim Form
Dental Claim Form
Health Benefit Summary Plan Description
Dental Benefit Plan Description
There is no deductible or co-pays applied when you stay within your Poughkeepsie Public School Teachers benefit plan and the General Vision Collection/Network.
- Comprehensive Eye Examination
- Selection of Various Frames: Up to a retail value of $200.00 (Within the GVS Collection).
- Selection of lens in plastic:
- Single Vision
- Conventional Bifocals
- Conventional Trifocals
- GVS Progressives Cosmetic & Rx Sun Tints included.
- Standard Soft Spherical Daily Wear
- Extended Wear Spherical Lenses
- A 6-month supply (4 boxes) of basic disposables are included. For any other contacts, patient will pay U&C retail less $200.
- AR Coating: $35
- Polycarb SV: Included in Rx only
- Polycarb FT28: $80
- GVS Progressives: $30
- Premium Progressives: $70
- Varilux Comfort: $120
- 1.60 High Index SV: $70
- 1.60 High Index FT28: $110
- Transitions 3 SV: $80
- Transitions 3 FT28: $150
- Trans High Index SV: $115
- Trans High Index FT 28: $125
- Loss/Broken Protection Plan: $25
For any frame over $200, the patient pays the retail price less $200 or less 30%. All other upgrades not listed, the patient pays the retail price less 30%. Members can receive an eye examination from a non-par provider and go in-network to a GVS provider to fulfill prescription.
To comply with the federal Transparency in Coverage Rule, UnitedHealthcare, UMR and HealthSCOPE Benefits creates and publishes the Machine-Readable Files on behalf of the PPSTA Benefit Trust. This link will be active July 1, 2022.
To link to the Machine-Readable Files, please click on the URL provided: https://transparency-in-coverage.uhc.com/
Out of Network Benefits
- Exam fee: $50
- Frames only: $100
- Single Vision only: $50
- Bifocal/Trifocal Additional: $60
- Contacts Complete: $150
- Lasik Surgery: $500.00 per eye
- Vision Benefits Link
Note: Benefit will be reimbursed to the member after receiving an authorization number and returning the appropriate claim form and receipts.
Loss/Broken Protection Plan is included with a 25.00 co-pay at time of loss for what is covered within your program if you go to a participating provider.
Benefit Trust Coordinator
Debbie Kardas firstname.lastname@example.org
Office hours: 10:30-1:30 Tuesday, Wednesday & Thursday
Call the PPSTA office @ 845-471-3376