Page 14 - Vidant Health 2021 Annual Enrollment Providers
P. 14
2021
Vision
The Vision Care Plan is designed to encourage you Once your beneit is effective, visit www.eyemed.com
to maintain your vision through regular exams and for details.
to help with expenses for prescription glasses and
contact lenses. For 2021, the vision care plan will be For more information, including plan limitations,
administered by EyeMed. With this voluntary plan, you exclusions, and discounted services; please refer to
may use in or out-of-network providers, but the level of the Vision Care summary plan description by visiting
beneit is higher when you receive care from a network www.AskPhin.com. Your provider will verify eligibility
provider. A listing of network providers can be found of beneits. Visit visit www.eyemed.com for details.
at www.eyemed.com or by calling EyeMed directly at
844-409-3401.
EyeMed Beneit Coverage In-Network Out-of-Network
Well Vision Exam
Focuses on your eyes
and overall wellness $20 copay Covered up to $44 retail
Every calendar year
Frames Included in Prescription Glasses
Every calendar year $150 allowance Covered up to $77 retail
20% of amount over your allowance
Lenses
Single vision, lined
bifocal, and lined $20 copay Covered up to $64 retail*
trifocal lenses
Every calendar year
Lens Option Scratch Coat: $13 copay | Ultraviolet coat: $15 copay
Tints, solid, or gradients: $15 copay | Anti-relective coat: $45 copay
Polycarbonate: $45 copay | High index 1.6: $55 copay
Photochromic: $75 copay
Contacts (instead of lenses) Fit & Follow Up Fit & Follow Up
Contact lens exam $25 copay (Standard) Up to $40
(itting and evaluation) $25 copay; 10% of retail price, then apply $40 allowance reimbursement
Every calendar year (Premium)
Contact Lenses Contact Lenses
Conventional—15% of balance over $150 allowance Up to $100
Disposable—$150 allowance reimbursement
Extra Savings and Discounts 40% of additional pairs of glasses once funded beneit is used
20% of any item not covered including non-prescription sunglasses
15% discount on conventional lenses once funded beneit is used Discounts may not be
Laser Vision Correction available for out-of-network
Lasik or PRK from US Laser Network 15% of retail price or 5% of providers
promotional price
40% of hearing exams and a low price guarantee on discount
hearing aids
* Single covered up to $34 retail; bifocal covered up to $48 retail; trifocal covered up to $64 retail
14
Vision
The Vision Care Plan is designed to encourage you Once your beneit is effective, visit www.eyemed.com
to maintain your vision through regular exams and for details.
to help with expenses for prescription glasses and
contact lenses. For 2021, the vision care plan will be For more information, including plan limitations,
administered by EyeMed. With this voluntary plan, you exclusions, and discounted services; please refer to
may use in or out-of-network providers, but the level of the Vision Care summary plan description by visiting
beneit is higher when you receive care from a network www.AskPhin.com. Your provider will verify eligibility
provider. A listing of network providers can be found of beneits. Visit visit www.eyemed.com for details.
at www.eyemed.com or by calling EyeMed directly at
844-409-3401.
EyeMed Beneit Coverage In-Network Out-of-Network
Well Vision Exam
Focuses on your eyes
and overall wellness $20 copay Covered up to $44 retail
Every calendar year
Frames Included in Prescription Glasses
Every calendar year $150 allowance Covered up to $77 retail
20% of amount over your allowance
Lenses
Single vision, lined
bifocal, and lined $20 copay Covered up to $64 retail*
trifocal lenses
Every calendar year
Lens Option Scratch Coat: $13 copay | Ultraviolet coat: $15 copay
Tints, solid, or gradients: $15 copay | Anti-relective coat: $45 copay
Polycarbonate: $45 copay | High index 1.6: $55 copay
Photochromic: $75 copay
Contacts (instead of lenses) Fit & Follow Up Fit & Follow Up
Contact lens exam $25 copay (Standard) Up to $40
(itting and evaluation) $25 copay; 10% of retail price, then apply $40 allowance reimbursement
Every calendar year (Premium)
Contact Lenses Contact Lenses
Conventional—15% of balance over $150 allowance Up to $100
Disposable—$150 allowance reimbursement
Extra Savings and Discounts 40% of additional pairs of glasses once funded beneit is used
20% of any item not covered including non-prescription sunglasses
15% discount on conventional lenses once funded beneit is used Discounts may not be
Laser Vision Correction available for out-of-network
Lasik or PRK from US Laser Network 15% of retail price or 5% of providers
promotional price
40% of hearing exams and a low price guarantee on discount
hearing aids
* Single covered up to $34 retail; bifocal covered up to $48 retail; trifocal covered up to $64 retail
14
