Page 12 - Thompson Coburn 2021 Annual Benefits Enrollment
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VISION PLAN
How the Plan Works
If you use an EyeMed provider, the plan pays for an eye exam every 12 months, after you make a $15 copayment.
You also receive a set allowance for frames every 24 months and a set allowance for contact lenses every 12
months. The plan pays for lenses for prescription glasses every 12 months, after you pay a $25 copayment.
In addition, you can receive extra discounts, including the following.
Paying no more than $55 for a contact lens itting and evaluation
15% off the regular price of laser vision correction or 5% off the promotional price from contracted
facilities
40% off a second, third, and fourth complete pair of eyeglass purchases once the funded beneit has been
used (includes prescription sunglasses)
For more information about your vision beneits and to see a complete list of member providers, visit
www.eyemed.com.
Vision Benefits Plan Design
In-Network Out-of-Network Frequency
Eye exams $15 copay You are reimbursed up to $35 Once every plan year
Prescription Glasses
Lenses
Single $25 copay You are reimbursed up to $25
Bifocal $25 copay You are reimbursed up to $40
Trifocal $25 copay You are reimbursed up to $60 Once every plan year
Polycarbonate $40 copay N/A
You receive a $150 allowance for
Frames frames, plus a 20% discount of any You are reimbursed up to $75 Once every two plan
years
amount over your allowance
Contact lenses—conventional You receive a $125 allowance, 15% of You are reimbursed up to $100 Once every plan year
balance over $125 (materials only)
Contact lenses—disposable You receive a $125 allowance, plus Once every plan year
balance over $125 (materials only)
Vision Premiums
Eligibility Options Per Pay Period Monthly Rate
Individual $2.63 $5.25
Individual + spouse $4.99 $9.98
Individual + child(ren) $5.26 $10.51
Individual + family $7.73 $15.45
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How the Plan Works
If you use an EyeMed provider, the plan pays for an eye exam every 12 months, after you make a $15 copayment.
You also receive a set allowance for frames every 24 months and a set allowance for contact lenses every 12
months. The plan pays for lenses for prescription glasses every 12 months, after you pay a $25 copayment.
In addition, you can receive extra discounts, including the following.
Paying no more than $55 for a contact lens itting and evaluation
15% off the regular price of laser vision correction or 5% off the promotional price from contracted
facilities
40% off a second, third, and fourth complete pair of eyeglass purchases once the funded beneit has been
used (includes prescription sunglasses)
For more information about your vision beneits and to see a complete list of member providers, visit
www.eyemed.com.
Vision Benefits Plan Design
In-Network Out-of-Network Frequency
Eye exams $15 copay You are reimbursed up to $35 Once every plan year
Prescription Glasses
Lenses
Single $25 copay You are reimbursed up to $25
Bifocal $25 copay You are reimbursed up to $40
Trifocal $25 copay You are reimbursed up to $60 Once every plan year
Polycarbonate $40 copay N/A
You receive a $150 allowance for
Frames frames, plus a 20% discount of any You are reimbursed up to $75 Once every two plan
years
amount over your allowance
Contact lenses—conventional You receive a $125 allowance, 15% of You are reimbursed up to $100 Once every plan year
balance over $125 (materials only)
Contact lenses—disposable You receive a $125 allowance, plus Once every plan year
balance over $125 (materials only)
Vision Premiums
Eligibility Options Per Pay Period Monthly Rate
Individual $2.63 $5.25
Individual + spouse $4.99 $9.98
Individual + child(ren) $5.26 $10.51
Individual + family $7.73 $15.45
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