Page 16 - Guide
P. 16
2017 Benefits Enrollment
Vision Coverage
Vision
Vision beneits are essential to maintaining your overall health and
well-being, which is why we are proud to offer vision coverage through
EyeMed Vision Care. You can apply your beneit toward any eye exam,
available frame, or brand of contact lenses which it your lifestyle.
Covered Services In-Network Out-of-Network
Beneit Frequency
Vision examination (Once every $10 copay Up to $30
12 months)
Standard contact lens (Once every Up to $40 N/A
it and follow up 12 months)
Eyeglass frames (Once every No copay, $120 Up to $60
24 months) allowance, 20%
Need additional off retail price over
$120
pairs of eyeglasses Standard lenses (Once every $25 copay Up to: $25/$40/$60
or do you wear Single vision/bifocal/ 12 months)
both eyeglasses and trifocal
contacts? Lenses options $15 N/A
Members are eligible for a 40% UV/tint/standard
scratch coating
discount off an additional eyeglass
purchase and a 15% discount off Polycarbonate/anti- $40/$45/20% off N/A
contacts once the funded beneit relective/polarized retail price
has been used. Conventional contact (Once every No copay, $135 Up to $108
lenses (in lieu of 12 months) allowance, 15%
glasses) off retail price over
$135
Laser vision 15% off retail N/A
price or 5% off
Find an In-Network correction lasik or promotional price
PRK from U.S. Laser
Provider Today! Network
Finding a convenient vision
care provider is easy. Visit This summary of beneits is intended to be a brief outline of coverage. The entire provisions of
www.eyemedvisioncare.com beneits and exclusions are contained in the summary plan description (SPD). In the event of a
conlict between the SPD and this description, the terms of the SPD will prevail.
and choose the SELECT Network
or call 866.299.1358 to locate Weekly Contribution Rates
a provider, or contact your local Employee $1.28
leading optical retailer such as Employee + spouse
LensCrafters Target Optical ®, $2.55
®,
JCPenney Optical Sears Optical ®, Employee + child(ren) $2.43
®,
and most Pearle Vision locations. Family $3.75
®
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Vision Coverage
Vision
Vision beneits are essential to maintaining your overall health and
well-being, which is why we are proud to offer vision coverage through
EyeMed Vision Care. You can apply your beneit toward any eye exam,
available frame, or brand of contact lenses which it your lifestyle.
Covered Services In-Network Out-of-Network
Beneit Frequency
Vision examination (Once every $10 copay Up to $30
12 months)
Standard contact lens (Once every Up to $40 N/A
it and follow up 12 months)
Eyeglass frames (Once every No copay, $120 Up to $60
24 months) allowance, 20%
Need additional off retail price over
$120
pairs of eyeglasses Standard lenses (Once every $25 copay Up to: $25/$40/$60
or do you wear Single vision/bifocal/ 12 months)
both eyeglasses and trifocal
contacts? Lenses options $15 N/A
Members are eligible for a 40% UV/tint/standard
scratch coating
discount off an additional eyeglass
purchase and a 15% discount off Polycarbonate/anti- $40/$45/20% off N/A
contacts once the funded beneit relective/polarized retail price
has been used. Conventional contact (Once every No copay, $135 Up to $108
lenses (in lieu of 12 months) allowance, 15%
glasses) off retail price over
$135
Laser vision 15% off retail N/A
price or 5% off
Find an In-Network correction lasik or promotional price
PRK from U.S. Laser
Provider Today! Network
Finding a convenient vision
care provider is easy. Visit This summary of beneits is intended to be a brief outline of coverage. The entire provisions of
www.eyemedvisioncare.com beneits and exclusions are contained in the summary plan description (SPD). In the event of a
conlict between the SPD and this description, the terms of the SPD will prevail.
and choose the SELECT Network
or call 866.299.1358 to locate Weekly Contribution Rates
a provider, or contact your local Employee $1.28
leading optical retailer such as Employee + spouse
LensCrafters Target Optical ®, $2.55
®,
JCPenney Optical Sears Optical ®, Employee + child(ren) $2.43
®,
and most Pearle Vision locations. Family $3.75
®
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