Medical & Dental

Summary of Benefits
OPTUMRx Information
Gym Reimbursement
Enrollment Form
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.

GVS Reimbursement Form


  • 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.
    • Contacts
    • 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.

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

Office hours: 10:30-1:30 Tuesday, Wednesday & Thursday
Call the PPSTA office @ 845-471-3376