Page 20 - CPS Benefits Guide

Davis Vision Semi-Monthly

Vision is offered through Davis Vision to all eligible employees, Employee $3.25
their spouses, and their dependent children, up to 26. Discounts Employee + 1 $5.84
are also offered on lasik and laser vision correction. Visit Employee + 2 $6.16
davisvision.com or call 800.999.5431. Employee and family $9.72

PPO Out-of-Network
Copay
Exam $20 copay Reimbursed up to $30
Lenses
Single Covered 100% Reimbursed up to $25
Bifocal Covered 100% Reimbursed up to $35
Trifocal Covered 100% Reimbursed up to $45
Lenticular Covered 100% Reimbursed up to $60
Frames
Covered 100% Reimbursed up to $30
Optional Fees
Premier Frame from the “Collection” $25 Not covered
Polycarbonate Lenses $30 Not covered
Single/Multifocal Scratch Protection Plan $20/$40 Not covered
Photochromic Lenses $20 Not covered
Blended Invisible Bifocals $20 Not covered
UV Coating $12 Not covered
Intermediate Vision Lenses $30 Not covered
Standard/Premium/Ultra ARC (anti-relective) $35/$48/$60 Not covered
Polarized Lenses $75 Not covered
Plastic Photosensitive Lenses $65 Not covered
High-Index (thinner and lighter) Lenses $55 Not covered
Standard/Premium Progressive Multifocal Lenses $50/$90 Not covered
Contacts
Medically Necessary Covered 100% Reimbursed up to $225
Elective (contacts in lieu of glasses) Covered 100% Reimbursed up to $75
Frequency
Exam 12 months 12 months
Lenses 12 months 12 months
Contacts (in lieu of glasses) 12 months 12 months
Frames 24 months 24 months

20 2017 Benefits Enrollment