Page 34 - SIH 2022 Re-Enrollment Guide
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VISION COVERAGE
SIH ofers a vision plan administered through Eyemed Vision Care. Eyemed ofers a large network of vision
providers, including chain and private practice providers.
The plan covers one vision exam each calendar year, which is covered 100% after your copay. The plan also
will pay a portion of the cost of either contacts or eyeglass lenses (but not both) once a year, and frames
every other year. You can also get a discount on LASIK or PRK from US Laser Network if you use an Eyemed
provider.
In-Network Member Out-of-Network In-Network Member Out-of-Network
Vision Care Services Vision Care Services
Cost Reimbursement Cost Reimbursement
Exam With Dilation as Necessary Frequency
$10 copay Up to $35 Once every 12
Examination Once every 12 months
Frames months
Lenses or Contact Once every 12
$0 copay; $120 Once every 12 months
allowance; 20% of Up to $50 Lenses months
balance over $120 Once every 24
Frame Once every 24 months
Standard Plastic Lenses months
Single Vision $25 copay Up to $25 Diabetic Care Services (Type 1 and Type 2 Diabetics)
Oice Service Visit—
Bifocal $25 copay Up to $40 Up to (2) Services Per Covered 100%, $0 Up to $77
Trifocal $25 copay Up to $55 Beneit Year copay
Standard Progressive $90 copay Up to $40 Covered 100%,
Lens Retinal Imaging—Up $0 copay (Not
$90 copay; 20% of to (2) Services Per covered if extended Up to $50
Premium Progressive retail price less $120 Up to $40 ophthalmoscopy is
Lens Beneit Year provided within 6
allowance
months)
Contact Lens Fit and Follow-Up (Contact lens it and two follow
up visits are available once a comprehensive eye exam has Extended Covered 100%, $0
been completed) Ophthalmoscopy—Up copay (Not covered
Standard Contact Lens Up to $55 N/A to (2) Services Per if retinal imaging is Up to $15
provided within 6
Fit and Follow-Up Beneit Year months)
Premium Contact Lens 10% of retail N/A
Fit and Follow-Up Gonioscopy—Up Covered 100%, $0
Contact Lenses to (2) Services Per copay Up to $15
Beneit Year
$0 copay; $120 Scanning Laser—Up
Conventional allowance; 15% of Up to $92 to (2) Services Per Covered 100%, $0 Up to $33
balance over $120 Beneit Year copay
$0 copay; $120
Disposable allowance; plus balance Up to $92
over $120
Medically Necessary $0 copay, paid-in-full Up to $200
To ind an Eyemed provider, please call 866.9.Eyemed (866.939.3633) or visit www.eyemedvisioncare.com.
Please note: if your spouse is also an employee of SIH, you will need to choose employee coverage under
your own plan or spouse or family coverage under your spouse’s plan. You cannot be enrolled in both.
The vision plan documents are available online by visiting Employee Self Service and Beneits Plans &
Coverage under the Home tab on the Lawson Dashboards and at beneits.sih.net. If you do not have access
to a computer, printed copies are available upon request from Human Resources.
34
SIH ofers a vision plan administered through Eyemed Vision Care. Eyemed ofers a large network of vision
providers, including chain and private practice providers.
The plan covers one vision exam each calendar year, which is covered 100% after your copay. The plan also
will pay a portion of the cost of either contacts or eyeglass lenses (but not both) once a year, and frames
every other year. You can also get a discount on LASIK or PRK from US Laser Network if you use an Eyemed
provider.
In-Network Member Out-of-Network In-Network Member Out-of-Network
Vision Care Services Vision Care Services
Cost Reimbursement Cost Reimbursement
Exam With Dilation as Necessary Frequency
$10 copay Up to $35 Once every 12
Examination Once every 12 months
Frames months
Lenses or Contact Once every 12
$0 copay; $120 Once every 12 months
allowance; 20% of Up to $50 Lenses months
balance over $120 Once every 24
Frame Once every 24 months
Standard Plastic Lenses months
Single Vision $25 copay Up to $25 Diabetic Care Services (Type 1 and Type 2 Diabetics)
Oice Service Visit—
Bifocal $25 copay Up to $40 Up to (2) Services Per Covered 100%, $0 Up to $77
Trifocal $25 copay Up to $55 Beneit Year copay
Standard Progressive $90 copay Up to $40 Covered 100%,
Lens Retinal Imaging—Up $0 copay (Not
$90 copay; 20% of to (2) Services Per covered if extended Up to $50
Premium Progressive retail price less $120 Up to $40 ophthalmoscopy is
Lens Beneit Year provided within 6
allowance
months)
Contact Lens Fit and Follow-Up (Contact lens it and two follow
up visits are available once a comprehensive eye exam has Extended Covered 100%, $0
been completed) Ophthalmoscopy—Up copay (Not covered
Standard Contact Lens Up to $55 N/A to (2) Services Per if retinal imaging is Up to $15
provided within 6
Fit and Follow-Up Beneit Year months)
Premium Contact Lens 10% of retail N/A
Fit and Follow-Up Gonioscopy—Up Covered 100%, $0
Contact Lenses to (2) Services Per copay Up to $15
Beneit Year
$0 copay; $120 Scanning Laser—Up
Conventional allowance; 15% of Up to $92 to (2) Services Per Covered 100%, $0 Up to $33
balance over $120 Beneit Year copay
$0 copay; $120
Disposable allowance; plus balance Up to $92
over $120
Medically Necessary $0 copay, paid-in-full Up to $200
To ind an Eyemed provider, please call 866.9.Eyemed (866.939.3633) or visit www.eyemedvisioncare.com.
Please note: if your spouse is also an employee of SIH, you will need to choose employee coverage under
your own plan or spouse or family coverage under your spouse’s plan. You cannot be enrolled in both.
The vision plan documents are available online by visiting Employee Self Service and Beneits Plans &
Coverage under the Home tab on the Lawson Dashboards and at beneits.sih.net. If you do not have access
to a computer, printed copies are available upon request from Human Resources.
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