Page 12 - Ideal Option 2020 New Hire Guide
P. 12
VISION
Finding In-Network
Providers We partner with EyeMed to offer you and your family members vision
Remember to visit in-network insurance. Visit www.eyemed.com to ind in-network providers and access
providers to receive the to a variety of online tools and programs.
deepest level of discount on
your services. In-Network Out-of-Network
Copay
To ind a participating in- Exam $10 copay Up to $40
network provider in your
area, go to eyemed.com or Retinal Imaging Up to $39 Not covered
call 866 .804 .0982 . Lenses
Single $25 copay Up to $30
Bifocal $25 copay Up to $50
Trifocal $25 copay Up to $70
Lenticular $25 copay Up to $70
Frames
$0 copay; 20% of balance Up to $91
over $130 allowance
Contacts
Conventional $0 copay; 15% of balance Up to $91
over $130 allowance
Disposable $0 copay; plus balance over Up to $91
$130 allowance
Medically Necessary $0 copay; paid in full Up to $210
Frequency
Exam Once every plan year
Lenses Once every plan year
Contacts (in lieu of glasses) Once every plan year
Frames Once every other plan year
This is a high level summary of your beneit coverage. Full coverage details are available in your
summary plan description (SPD). In the event there is a discrepancy between what is relected in
this guide and what is communicated in your SPD, the terms of your SPD will prevail.
Employee Bi-Weekly Vision Contributions
Employee Only $1 .17
Employee + Spouse $2 .22
Employee + Child(ren) $2 .34
Family $3 .44
12
Finding In-Network
Providers We partner with EyeMed to offer you and your family members vision
Remember to visit in-network insurance. Visit www.eyemed.com to ind in-network providers and access
providers to receive the to a variety of online tools and programs.
deepest level of discount on
your services. In-Network Out-of-Network
Copay
To ind a participating in- Exam $10 copay Up to $40
network provider in your
area, go to eyemed.com or Retinal Imaging Up to $39 Not covered
call 866 .804 .0982 . Lenses
Single $25 copay Up to $30
Bifocal $25 copay Up to $50
Trifocal $25 copay Up to $70
Lenticular $25 copay Up to $70
Frames
$0 copay; 20% of balance Up to $91
over $130 allowance
Contacts
Conventional $0 copay; 15% of balance Up to $91
over $130 allowance
Disposable $0 copay; plus balance over Up to $91
$130 allowance
Medically Necessary $0 copay; paid in full Up to $210
Frequency
Exam Once every plan year
Lenses Once every plan year
Contacts (in lieu of glasses) Once every plan year
Frames Once every other plan year
This is a high level summary of your beneit coverage. Full coverage details are available in your
summary plan description (SPD). In the event there is a discrepancy between what is relected in
this guide and what is communicated in your SPD, the terms of your SPD will prevail.
Employee Bi-Weekly Vision Contributions
Employee Only $1 .17
Employee + Spouse $2 .22
Employee + Child(ren) $2 .34
Family $3 .44
12
