Page 12 - CHI 2022 Benefits Guide
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Vision Benefits
If you and your family members need eye care, you have the option to enroll in the vision plan through
EyeMed.
EyeMed’s large vision plan provider network ofers you access to private practice optometrists and
ophthalmologists, conveniently located retail chain providers, and discounted laser eye surgery from pre-
screened providers. When you visit in-network providers, the plan covers your vision care services at higher
rates and participating providers will submit your claim to EyeMed.
Vision Plan Summary
EyeMed
In-Network Out-of-Network
Vision Exam $10 copay Up to $40
Lenses $25 copay
Single-Vision Covered in full Up to $30
Bifocal Covered in full Up to $50
Trifocal Covered in full Up to $70
Lenticular Covered in full Up to $70
Progressive $90-$135 copay Up to $50
$150 allowance
Frames 20% of balance over $150 Up to $105
Contact Lenses (in lieu of glasses)
$150 allowance
Contact Lenses 15% of balance over $150 Up to $150
Medically Necessary for Speciic Covered in full Up to $210
Conditions
Standard Contact Lens Exam Fitting Up to $40 copay Not covered
Beneit Frequency
Exam 12 months
Lenses or Contact Lenses 12 months
Frames 12 months
This summary is a highlight of the beneit provisions and should not be relied upon as a complete detailed representation of the plan.
To locate an EyeMed participating provider, visit www.eyemed.com or call 866.800.5457. Search providers in the
Insight Network.
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If you and your family members need eye care, you have the option to enroll in the vision plan through
EyeMed.
EyeMed’s large vision plan provider network ofers you access to private practice optometrists and
ophthalmologists, conveniently located retail chain providers, and discounted laser eye surgery from pre-
screened providers. When you visit in-network providers, the plan covers your vision care services at higher
rates and participating providers will submit your claim to EyeMed.
Vision Plan Summary
EyeMed
In-Network Out-of-Network
Vision Exam $10 copay Up to $40
Lenses $25 copay
Single-Vision Covered in full Up to $30
Bifocal Covered in full Up to $50
Trifocal Covered in full Up to $70
Lenticular Covered in full Up to $70
Progressive $90-$135 copay Up to $50
$150 allowance
Frames 20% of balance over $150 Up to $105
Contact Lenses (in lieu of glasses)
$150 allowance
Contact Lenses 15% of balance over $150 Up to $150
Medically Necessary for Speciic Covered in full Up to $210
Conditions
Standard Contact Lens Exam Fitting Up to $40 copay Not covered
Beneit Frequency
Exam 12 months
Lenses or Contact Lenses 12 months
Frames 12 months
This summary is a highlight of the beneit provisions and should not be relied upon as a complete detailed representation of the plan.
To locate an EyeMed participating provider, visit www.eyemed.com or call 866.800.5457. Search providers in the
Insight Network.
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