Page 33 - 17BE 2930
P. 33
Vision
Vision Plan Summary of Benefits—Vision
The Carlstar Group understands Vision Care Services In Network Member Cost Out-of-Network
the importance of taking care Exam with dilation as $10 copay Reimbursement
Up to $30
of your eyesight. The vision necessary
coverage offered by The Carlstar Contact Lens Fit and Follow-Up (Contact lens it and two follow up visits are available
once a comprehensive eye exam has been completed.)
Group promotes preventive care Standard contact lens it Up to $40 N/A
via regular eye exams and early and follow-up premium 10% off retail N/A
contact lens it and follow-
corrective treatment. Besides up
helping you see better, routine Frames $0 Copay; $150 allowance; 20% Up to $75
eye exams can detect a number off retail price over $150
of serious health conditions Standard Plastic Lenses
such as glaucoma, cataracts, and Single vision $15 copay Up to $25
Bifocal
Up to $40
$15 copay
diabetes. In addition, eye exams Trifocal $15 copay Up to $55
for your dependent children can Standard progressive lens $80 Up to $40
spot problems, which can impact Premium progressive $80, 80% of charge less $120 Up to $40
allowance
their learning. You may enroll for Lenticular $15 copay Up to $55
employee, employee and spouse, Lens Options (Paid by the member and added to the base price of the lens.)
N/A
UV Treatment
$15
employee and child(ren), or family Tint (solid and gradient) $15 N/A
coverage. Vision coverage is Standard plastic scratch $ 0 Up to $11
through EyeMed Vision Care. coating $40 N/A
Standard polycarbonate
Standard polycarbonate— $ 0 Up to $28
Your Cost kids under 19 $45 N/A
Standard anti-relective
Your cost for vision coverage coating 20% off retail price N/A
Polarized
is deducted from your pay on a Other add-ons and services 20% off retail price N/A
pretax basis. Refer to page 46 titled
“Employee Contributions” for the
cost applicable to vision coverage
offered by The Carlstar Group. For a complete list of providers near you, use our Provider Locator on
See HR or Safety Department to www.eyemedvisioncare.com and choose the SELECT network or call
obtain prescription safety glasses 866.299.1358 Lasik providers, call 877.5LASER6
required for work.
33
Vision Plan Summary of Benefits—Vision
The Carlstar Group understands Vision Care Services In Network Member Cost Out-of-Network
the importance of taking care Exam with dilation as $10 copay Reimbursement
Up to $30
of your eyesight. The vision necessary
coverage offered by The Carlstar Contact Lens Fit and Follow-Up (Contact lens it and two follow up visits are available
once a comprehensive eye exam has been completed.)
Group promotes preventive care Standard contact lens it Up to $40 N/A
via regular eye exams and early and follow-up premium 10% off retail N/A
contact lens it and follow-
corrective treatment. Besides up
helping you see better, routine Frames $0 Copay; $150 allowance; 20% Up to $75
eye exams can detect a number off retail price over $150
of serious health conditions Standard Plastic Lenses
such as glaucoma, cataracts, and Single vision $15 copay Up to $25
Bifocal
Up to $40
$15 copay
diabetes. In addition, eye exams Trifocal $15 copay Up to $55
for your dependent children can Standard progressive lens $80 Up to $40
spot problems, which can impact Premium progressive $80, 80% of charge less $120 Up to $40
allowance
their learning. You may enroll for Lenticular $15 copay Up to $55
employee, employee and spouse, Lens Options (Paid by the member and added to the base price of the lens.)
N/A
UV Treatment
$15
employee and child(ren), or family Tint (solid and gradient) $15 N/A
coverage. Vision coverage is Standard plastic scratch $ 0 Up to $11
through EyeMed Vision Care. coating $40 N/A
Standard polycarbonate
Standard polycarbonate— $ 0 Up to $28
Your Cost kids under 19 $45 N/A
Standard anti-relective
Your cost for vision coverage coating 20% off retail price N/A
Polarized
is deducted from your pay on a Other add-ons and services 20% off retail price N/A
pretax basis. Refer to page 46 titled
“Employee Contributions” for the
cost applicable to vision coverage
offered by The Carlstar Group. For a complete list of providers near you, use our Provider Locator on
See HR or Safety Department to www.eyemedvisioncare.com and choose the SELECT network or call
obtain prescription safety glasses 866.299.1358 Lasik providers, call 877.5LASER6
required for work.
33
