Welcome Costco Employees

Costco Vision Voucher Request Form

Effective January 1, 2009, Costco's Vision Care Plan coverage for eyewear will be changed to a one-time annual benefit of $150 per person. When this change goes into effect you will no longer need to obtain a vision voucher to purchase eyewear under the Vision Care Plan. Costco Optical Departments will be able to process an order for eyewear by employee name and identification. Therefore, any vision voucher issued in 2008 must be ordered and used no later than 12/31/08. If you receive or use your 2008 vision voucher after 12/31/08, it will be applied towards your 2009 vision benefit.

Instructions: Complete the fields below then click the "Send" button below. If you are eligible, the vision voucher will be mailed to the address you provide below. If you do not receive your voucher within 2 weeks, contact Aetna Member Services at 1-800-814-3543.

Should you need special assistance obtaining a voucher (such as in the case of an emergency), please do not use this form, instead, contact Aetna Member Services at 1-800-814-3543.

Note: this information will be encrypted for your protection before sending to Aetna.

Name of Employee:

Home Phone:

E-mail Address:

Aetna ID Number:

Please note that your Aetna ID Number begins with the letter "W."
See note and image below for more information.

Street Address:

Apartment #:

City, State:

Zip Code:

Is this voucher for:

Employee

Dependent(s), if so complete the following:

Special
Circumstances:
Use this space to
specify alternate
addresses, account
changes, additional
dependents and their
relationshp, etc.

Dependent Name 1:

Relationship 1:

Dependent Name 2:

Relationship 2:

Dependent Name 3:

Relationship 3:

(press Send button ONCE only)

Note:
"Where do I find my 'Aetna ID Number'?" Your Aetna ID number - sometimes called your Aetna Subscriber number - can be found on the face of your Aetna medical card. The following illustration highlights where the number is located on your card: