The following client details apply to Raytheon Technologies members only. Please refer to the Patient Record Report to confirm coordination or benefits restriction applies.

Raytheon employee vision benefits are embedded within the member’s medical policy. COB is not allowed with a member’s health plan and is only allowed with another vision plan.

If the health plan or Medicare is primary for:

• Exam Only: Bill us as primary for materials. Do not submit a coordination of benefits for the exam.
• Exam and Material: Coordination of benefits is not allowed for any portion of the exam or materials.

If another vision plan is primary, enter the vision carrier's name in Box 19.

• Example: “Primary vision carrier is XXXXXXX”

Bill Necessary Contact Lens claims resulting from injury to the eyes or cataract surgery to the patient’s medical plan.

The following client details apply to Raytheon Technologies (RTX) members only. Please refer to the VSP Safety Eyecare Plan in the Plans and Coverages section for complete Safety Eyecare information for these members.

Before scheduling an appointment, Raytheon members must get a signed “Raytheon Technologies ProTec Eyewear Authorization Form” from Raytheon. Although not required, Raytheon members may also present the VSP Safety Requirements Questionnaire at the time of their exam. Please put all applicable forms in the patient’s file.

There are two ways to get authorization:

• Online: Log on to eyefinity.com, select Get Authorization & Check Eligibility, and then select Member Search.
• By phone: Call VSP at 800.615.1883. You’ll need to provide the name of the Raytheon supervisor who approved the benefit to our Customer Service Representative to get an authorization.

Copay

Exam – No co pay.

Materials – No copay.

Under the ProTec Safety Plan, Raytheon members are eligible for a fully covered safety frame from the ProTec Eyewear^® frame kit and single-vision, lined bifocal, or trifocal polycarbonate lenses. Detachable side shields and a frame case are provided with each order through the participating labs.

The following limitations and requirements apply to Raytheon members:

• Safety glasses are available to the employee only.
• Polycarbonate lenses are preferred and covered.
• Permanent or removable side shields are required for all frames and are covered for ProTec Eyewear frames.
• If permanent side shields are required, it will be noted on the member’s Raytheon Technologies ProTec Eyewear Authorization form. Note: When billing on eyefinity.com enter “permanent side shields” in Lab Special Instructions on Invoice Services page of eClaim.
• All ProTec Safety and Repair/Replace orders must be sent to participating labs.
• Frames for electricians must be made from non-metallic materials.

Repair/Replace Benefits

Raytheon employees must provide a signed “Raytheon Technologies Safety Eyewear Authorization Form” before they can receive repair/replacement safety services or materials.

After using their materials benefit under their ProTec Safety plan, Raytheon members have an additional Repair/Replace benefit for their safety eyewear which covers materials.

• Raytheon members are eligible for repair/replacement if their spectacle lenses or frames are broken or damaged.
• Eligible Raytheon members covered under this additional benefit are entitled to safety eyeglass lens and safety frame repair/replacement.
• Frame repair includes temples only, front only, hinge, and miscellaneous repairs.
• The repair benefit may also include replacement of a complete frame and/or basic lens based on your professional judgment.

The following limitations and requirements apply to Raytheon members:

• For Raytheon members that supply a non-ProTec Eyewear frame to have lenses replaced, order must be sent to participating labs.
• For Raytheon members that supply a non-ProTec Eyewear frame for repair/replacement, previous safety frame must be replaced with a selected ProTec Eyewear model.
• For new frames, Raytheon members must choose one of the 30 ANSI-approved frames from the ProTec Eyewear kit or online catalog which are fully covered.