Vision Plan Enrollment Authorization (STD. 700)
Premier Vision Enrollment Authorization (CalHR 774)
Permitting Event Codes/Effective Dates Chart - Basic Plan
D - Vision Plan Direct Payment Authorization (STD 703)
Retiree Vision Plan Enrollment Authorization (CalHR 695)
Permitting Event Codes/Effective Dates Chart - Retirees
Permitting Event Codes/Effective Dates Chart - Premier Plan | Permitting Event Codes/Effective Dates Chart - Premier Plan - Text Only (RTF)
There will be no premium increases, increase in employee contributions, or benefit changes for the Premier Vision Plan. Retirees now have the option of the Premier Vision Plan.
When an employee retires, personnel office MUST offer retiree vision or COBRA continuation of active state coverage.
Currently there is not a Premier vision (enhanced) plan for retirees/annuitants. However, if a retiring employee is already enrolled in the Premier vision plan for active employees at the time of retirement, then the retiring employee may continue the Premier through COBRA only up to 18 months by completing the CalHR 774 Premier Vision Form and checking the "New COBRA Enrollment" box.
Eligible survivors (survivorship as determined by CalPERS), may enroll in the Retiree/Annuitant Vision Program.
Retirees/Annuitants Eligibility (G.C. Sec. 22959.4 requirements)
state retirees/annuitants are eligible for enrollment into the Retiree Vision Program if any of the following apply:
Enrollment into the state's Basic Vision Plan for eligible employees and their eligible dependents is automatic. The effective date of enrollment is based on when the Personnel Office keys an employee's Personnel Action Request (PAR) document into the State Controller's Office (SCO) payroll system. Eligible dependents are automatically enrolled at the same time that an employee's enrollment becomes effective. (Note: STD. 700 must be completed for Permanent Intermittent employees' enrollments.)
The following situations will require completion of a Vision Plan Enrollment Authorization, STD. 700 to enroll in or cancel coverage. See
Attachment C - Permitting Event Codes/Effective Dates Chart - Basic Vision Plan for information regarding permitting event codes.
For permanent intermittent employees wanting to enroll into the Premier Vision Plan, the STD. 700 needs to be completed in order to process the employer's contribution and deduction. In addition to the STD. 700, the CalHR 774 MUST ALSO be completed in order to enroll a member into Premier Vision. The STD. 700 should be sent to SCO and the CalHR 774 is to be sent to VSP's mailing address.
The completion of a STD.700 or CalHR 774 is required for deleting ineligible dependents off an active employee’s vision plan. Deletion documents will need to be sent to Vision Service Plan with a copy retained in the employee’ s personnel file. The CalHR 695 is not required for deletion of ineligible dependents. Employees who have dependents should be advised that ineligible dependents are not permitted to use the state's vision plan. Employees and retirees will be held liable for payment of services that are provided to ineligible dependents.
Standard Eye Examination and Glasses:
Employees/retirees/dependents may obtain covered services or materials from any other licensed optometrist, ophthalmologist, or optician of their choice. Services obtained through non-member doctors are subject to the same deductibles and limitations as services through VSP member doctors. The doctor must be paid in full and an itemized receipt is submitted to VSP. VSP will reimburse the employee/retiree/dependent up to the amounts allowed under the state plan's non- member doctor schedule. The reimbursement schedule does not guarantee full payment nor can VSP guarantee patient satisfaction when services are received from a non-member doctor.
Mark the form for the plan selection (Basic or Premier Vision plan). Please mail completed CalHR 695 form to VSP's mailing address or fax to VSP at (916) 463-9031 for processing. See
Section 1214 for address to send the