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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 Once every
up to $35 plan year
Prescription Glasses
Lenses
Single $25 copay You are reimbursed Once every
up to $25 plan year
Vision Premiums Bifocal $25 copay You are reimbursed
Eligibility Per Pay Monthly up to $40
Options Period Rate Trifocal $25 copay You are reimbursed
up to $60
Individual $2.63 $5.25 Polycarbonate $40 copay N/A
Individual + $4.99 $9.98 Frames You receive a $150 You are reimbursed Once every
spouse allowance for frames, plus up to $75 two plan
Individual + $5.26 $10.51 a 20% discount of any years
child(ren) amount over your allowance
Individual + $7.73 $15.45 Contact lenses— You receive a $125 You are reimbursed Once every
family conventional allowance, 15% of balance Up to $100 plan year
over $125 (materials only)
Contact lenses— You receive a $125 Once every
disposable allowance, plus balance over plan year
$125 (materials only)
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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 Once every
up to $35 plan year
Prescription Glasses
Lenses
Single $25 copay You are reimbursed Once every
up to $25 plan year
Vision Premiums Bifocal $25 copay You are reimbursed
Eligibility Per Pay Monthly up to $40
Options Period Rate Trifocal $25 copay You are reimbursed
up to $60
Individual $2.63 $5.25 Polycarbonate $40 copay N/A
Individual + $4.99 $9.98 Frames You receive a $150 You are reimbursed Once every
spouse allowance for frames, plus up to $75 two plan
Individual + $5.26 $10.51 a 20% discount of any years
child(ren) amount over your allowance
Individual + $7.73 $15.45 Contact lenses— You receive a $125 You are reimbursed Once every
family conventional allowance, 15% of balance Up to $100 plan year
over $125 (materials only)
Contact lenses— You receive a $125 Once every
disposable allowance, plus balance over plan year
$125 (materials only)
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