To receive our Vision Care Plan reimbursement, please complete the lower portion of this claim form and attach the entire form,
along with an original itemized receipt to your case request with OneSource. To create a case, please follow the steps provided
below. For assistance creating your case, please contact OneSource Faculty and Staff Service Center at: 732-745-7378 (SERV) or
visit our Self Service Portal.
IMPORTANT INFORMATION NEEDED FROM YOU:
1) An o
riginal item
ized receipt should include the following:
Name of the person receiving the lenses or
contacts;
Name of optometrist or provider.
Date of lens purchase;
Cost of lenses (must be shown separately from
frames, eye exam or fittings);
Type of lenses (e.g. single-vision, bifocals, trifocals,
contacts with # of boxes);
2) You and each of your eligible dependents are entitled to receive one reimbursement for lenses purchased in a
designated two-year contract period. Up to $45 may be reimbursed for the purchase of single-vision lenses or
contacts, and up to $50 for bifocal / trifocal lenses or contacts. For all contact lenses, 1 box per eye will be reimbursed,
not exceeding the $45 or $50 total amount.
3)
Please be advised that the Rutgers University vision care plan does not apply to RBHS employees, except for the units
OPEIU Local 153, HPAE 5089, 5135, 5094, CWA 1031 and 1040, IOUE Local 68 and Teamsters Local 97 are eligible (effective
July 1, 2019).
4)
The Vision Care Plan does not reimburse for: frames, coatings, exams, fittings, eyecare supplies or lens tinting.
5)
TheVision Care Plan does not reimburse for purchases made through Groupon, Living Social or similar social
media discount programs.
PLEASE COMPLETE THE FOLLOWING:
Employee’s Name: Employee ID #:
Campus Department / Address:
Name of Person Receiving Lenses: Date of Birth:
Relationship to employee (please check):
☐ Self
☐ Spouse
☐ Child ☐ Civil Union / Domestic Partner ☐ Civil Union / Domestic Partner’s Child
Lens Purchase Date: # of Boxes of Contacts (If Applicable):
Type of lenses (please check): ☐Single-Vision / Contacts ☐ Progressive/Bifocal/Trifocal/Contacts
NOTE: Your claim CANNOT be processed without attaching a receipt that
itemizes the above information.
**IF NOT SIGNED, FORM WILL BE RETURNED**
Employee’s Signature: Date:
VISION CARE PLAN CLAIM FORM
1. Go to – onesource.rutgers.edu – log in using your NetID and password
2.
Click on ‘Service Catalog’ found across the top right-hand side of page
3. Select ‘Benefits’ from the categories list shown on the left-hand side of page
4. Select ‘Vision Reimbursement Request’ from the list of items
5. Fill out the form as it pertains to you
6.
Click on the ‘paper clip’ icon to attach your supporting
documentation
(completed form and itemized receipt)
7. Click on ‘Submit’ to create your case
FREQUENTLY ASKED QUESTIONS
Who is eligible?
• Regularly appointed full-time faculty / staff in legacy
Rutgers positions (Class 1, 3 and 6 employees)
• Legal spouse or registered same-sex civil union or
same-sex domestic partner of eligible employee.
• Eligible children until the end of the year in which the
26
th
birthday occurs.
• Rutgers employees in legacy UMDNJ positions,
OPEIU Local 153, HPAE 5089, 5135, 5094, CWA 1031
and 1040, IOUE Local 68 and Teamsters Local 97 as of
July 1, 2019 are eligible.
When can new employees use the
program?
Academic Year – 10 month employees with a September 1
hire date are eligible September 1
st
.
Calendar Year – 12 month employees are eligible after 2
months of continuous employment (i.e. August 15 hire
date = October 15 effective date).
What are the benefits?
• Up to $45 reimbursement for purchase of single-vision
eyeglasses or contact lenses.
• Up to $50 reimbursement for purchase of bifocal or trifocal
lenses or contact lenses.
• For all contact lenses, 1 box per eye will be reimbursed, for a
maximum benefit of up to $45 for single-vision contacts and
up to $50 for bifocal / multifocal contacts. If your purchase
exceeds the maximum benefit, your reimbursement will be
$45 for single-vision contacts and $50 for bifocal / multifocal
contacts.
How often can an eligible member be
reimbursed?
Once every 2-year contract period
Current contract period = July 1, 2023 – June 30, 2025
How long does it take to receive
reimbursement?
Please allow 1 – 2 weeks for processing. Vision Care
reimbursement will be included in your regular paycheck,
under the code "VisionReim."
Is the reimbursement taxable income?
No, reimbursements are not taxable.
When does coverage terminate?
Academic Year – 10 month employees – coverage is
suspended July and August, and resumes September 1
if reappointed.
Calendar Year – 12 month employees – coverage
continues until the end of the month of the last day in
active pay status.
What purchases are not eligible for
reimbursement under the provisions of
the Vision Care Plan?
The Vision Care Plan does not reimburse for the following
purchases:
• Frames, coatings, exams, fittings, supplies or lens
tinting
• Purchases made through Groupon / Living Social
or other social media discount providers.
VISION CARE PLAN CLAIM FORM
