Page 22 - AESC 2019 Benefits Gudie

Vision Plan Details

EyeMed
Base Plan Enhanced Plan
In-Network Out-of-Network In-Network Out-of-Network
Copay
Exam $0 copay Up to $40 $0 copay Up to $40
Standard Contact Lens $40 N/A $0 copay; paid in full Up to $40
Fit and Follow-Up (2 visits)

Premium Contact Lens 10% off retail price N/A $0 copay; 10% off Up to $40
Fit and Follow-Up (2 visits) retail price; then
apply $55 allowance
Retinal Imaging Up to $39 N/A Up to $39 N/A
Lenses
Single $10 copay Up to $30 $0 copay Up to $30
Bifocal $10 copay Up to $50 $0 copay Up to $50
Trifocal $10 copay Up to $70 $0 copay Up to $70
Lenticular $10 copay Up to $70 $0 copay Up to $70
Standard Progressive $75 copay Up to $50 $0 copay Up to $96
Lens Options
UV Treatment $15 N/A $0 Up to $12
Tint (Solid and Gradient) $15 N/A $0 Up to $12
Scratch Coating $15 N/A $0 Up to $12
Polycarbonate $40 N/A $0 Up to $32
Photochromic (Plastic) $75 N/A $75 N/A
Anti-Reflective $45/$57/$68/20% N/A $0/$12/$23/20% off Up to $5
(Standard/Tier 1/2/3) off retail price retail price (except Tier 3)
Other Add-Ons and 20% off retail price N/A 20% off retail price N/A
Services
Frames
$0 copay; $100 Up to $56 $0 copay; $160 Up to $112
allowance; 20% off allowance; 20% off
balance over $100 balance over $160
Contacts
Conventional $0 copay; $100 Up to $80 $0 copay; $160 Up to $160
allowance; 15% off allowance; 15% off
balance over $100 balance over $160
Disposable $0 copay; $100 Up to $80 $0 copay; $160 Up to $160
allowance; allowance; plus
plus balance over balance over $160
$100
Medically Necessary $0 copay; paid in full Up to $210 $0 copay; paid in full Up to $210
Laser Vision Correction 15% off retail price or N/A 15% off retail price or N/A
5% off promotional 5% off promotional
price price
Frequency
Exam 12 months 12 months
Lenses 12 months 12 months
Contacts (in lieu of glasses) 12 months 12 months
Frames 24 months 12 months

22 2019 Benefits Enrollment