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Finding In-Network Vision
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
provider to receive the access to a variety of online tools and programs.
deepest level of discount on
your services. In-Network Out-of-Network
Copay
To find a participating in- Exam Covered 100% Up to $40
network dentist in your area,
go to www.eyemed.com or Materials $10 Copay
call 866.939.3633. Lenses
Single Covered 100% Up to $30
Bifocal after $10 copay Up to $50
Trifocal Up to $70
Lenticular Up to $70
Standard Scratch Coating Covered 100% Up to $5
Frames
Up to $130 Up to $91
(20% discount of
remaining balance)
Contacts
Elective $100 allowance, 15% Up to $70
of remaining balance
Medically Necessary Covered 100% Up to $210
Contact Lens Fit/Follow-Up
Fit and Follow-Up—Standard $40
Fit and Follow-Up—Premium 10% of retail price
Frequency
Exam 12 months
Lenses 12 months
Contacts (in lieu of glasses) 12 months
Frames 24 months
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.
20 2020 Benefits Guide
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
provider to receive the access to a variety of online tools and programs.
deepest level of discount on
your services. In-Network Out-of-Network
Copay
To find a participating in- Exam Covered 100% Up to $40
network dentist in your area,
go to www.eyemed.com or Materials $10 Copay
call 866.939.3633. Lenses
Single Covered 100% Up to $30
Bifocal after $10 copay Up to $50
Trifocal Up to $70
Lenticular Up to $70
Standard Scratch Coating Covered 100% Up to $5
Frames
Up to $130 Up to $91
(20% discount of
remaining balance)
Contacts
Elective $100 allowance, 15% Up to $70
of remaining balance
Medically Necessary Covered 100% Up to $210
Contact Lens Fit/Follow-Up
Fit and Follow-Up—Standard $40
Fit and Follow-Up—Premium 10% of retail price
Frequency
Exam 12 months
Lenses 12 months
Contacts (in lieu of glasses) 12 months
Frames 24 months
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.
20 2020 Benefits Guide
