![]() If you have to file a medical claim with Empire for reimbursement, download and fill out the Empire Claim Form (PDF).Beyond 20/20 Optometry Terms & Conditions Scope and Purpose of this Disclaimer In order to receive payment for a non-network provider you must complete the Empire Blue Cross claim form and submit the claim directly to Empire Blue Cross. If you choose a non-participating provider, you will be responsible for paying any cost beyond the Health and Benefit Fund’s maximum allowance of $1,000 per eye for Laser Vision correction surgery. You may also obtain Laser Vision correction services from any non-participating provider you choose. You may contact Davis Vision directly at 85 or log onto Once logged onto the Davis Vision website the client code for Local 94 Health and Benefit Fund is 7084. The Fund allows $1,000 per eye for Lasik surgery. To submit vision claims, you must complete and return the appropriate form to the Fund Office:ĭavis Vision is a participating vendor for Lasik surgery only. ![]() Please call the Fund Office or click on the vision care network links above for lists of participating GVS, CPS and Vision Screening locations and phone numbers to call to schedule an appointment. There is no out-of-pocket expense provided the lenses and frames you select are within the variety of lenses and frames offered under the Fund. The Fund presently has an arrangement with three vision care networks General Vision Services (“GVS”), Comprehensive Professional Systems (CPS) and Vision Screening that have agreed to accept the Fund’s fee schedule for the selected eye care as payment in full. The Fund provides benefits for one eye exam and lens(es) per calendar year.
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