Page 11 - Polyventive 2022 Benefits Guide
P. 11
2022 Benefits Guide
Vision
EyeMed Vision Plan
Polyventive will ofer vision coverage through
EyeMed. Participating providers include national
chains such as LensCrafters, Pearle Vision, Sears
Optical, Target Optical, and many other vision
centers. Please visit www.eyemedvisioncare.com
for a complete listing of participating providers.
In-Network Out-of-Network
Eye Exam $10 copay Up to $40
(every 12 months)
Lenses (every 12
months)
Single Lens $25 copay Up to $30
Bifocal Lens Up to $50
Trifocal Lens Up to $70
Lenticular Up to $70
Covered in full;
basic frame
Frames (every 24 allowance $130, Up to $91
months) plus a 20%
discount on any
overage
$130 allowance to
purchase contact
Contact Lens lenses; Up to $130
plus 15% discount
on any overage
Bi-Weekly Employee
Contributions
Employee Contribution
Employee $2.88
Employee + Spouse $5.18
Employee + Child(ren) $5.47
Family $8.64
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Vision
EyeMed Vision Plan
Polyventive will ofer vision coverage through
EyeMed. Participating providers include national
chains such as LensCrafters, Pearle Vision, Sears
Optical, Target Optical, and many other vision
centers. Please visit www.eyemedvisioncare.com
for a complete listing of participating providers.
In-Network Out-of-Network
Eye Exam $10 copay Up to $40
(every 12 months)
Lenses (every 12
months)
Single Lens $25 copay Up to $30
Bifocal Lens Up to $50
Trifocal Lens Up to $70
Lenticular Up to $70
Covered in full;
basic frame
Frames (every 24 allowance $130, Up to $91
months) plus a 20%
discount on any
overage
$130 allowance to
purchase contact
Contact Lens lenses; Up to $130
plus 15% discount
on any overage
Bi-Weekly Employee
Contributions
Employee Contribution
Employee $2.88
Employee + Spouse $5.18
Employee + Child(ren) $5.47
Family $8.64
11
