Page 9 - C.J. Segerstrom 2022 Benefit Guide

VISION PLAN

The vision plan provides coverage for routine eye exams and pays for all or a portion of the cost of glasses
or contact lenses. You can choose any provider; however, you always save money if you see in-network
providers. Your vision plan is provided through EyeMed.

Vision Care Services In-Network Member Cost Out-Of-Network Member Reimbursement

EXAM SERVICES
Exam at PLUS Providers $0 copay Up to $42
Exam $10 copay Up to $42
Fit and Follow-up – Standard $0 copay; contact lens fit and two follow-up visits Up to $40
Fit and Follow-up - Premium $0 copay; 10% off retail price, then apply Up to $40
$55 allowance

Frame
Any available frame at PLUS Providers $0 copay; 20% off balance over $180 allowance Up to $65
Frame $0 copay; 20% off balance over $130 allowance Up to $65
Lenses
(Contact Lens allowance includes materials only)
Contacts – Conventional $0 copay; 15% off balance over $130 allowance Up to $104
Contacts – Disposable $0 copay; 100% of balance over $130 allowance Up to $104
Contacts - Medically Necessary $0 copay; paid-in-full Up to $210

Standard Plastic Lenses
Single Vision $25 copay Up to $35
Bifocal $25 copay Up to $49
Trifocal $25 copay Up to $74
Progressive – Standard $90 copay Up to $49
Progressive - Premium $90 copay, 20% off retail price less $120 allowance Up to $49

Bi-weekly Cost
Employee Only $3.51
Employee + Spouse $6.65

Employee + Child(ren) $7.00
Employee + Family $10.27

Get the most out of your vision plan with these EyeMed highlights:
• Eye360 features a $0 eye exam and an additional $50 added to your frame allowance at PLUS Providers
• Ability to use the frame and contact lens allowances in the same benefit year – worth up to an extra $130
• Separate contact lens fit & follow-up coverage (leaving the entire allowance for materials)

How to Find a Vision Provider
1. Go to www.eyemed.com
2. Click on Find an Eye Doctor
3. Select the Access Network and enter your zip code
4. Remember our plan includes enhanced benefits at PLUS Provider locations within the network. Going to one may
maximize your benefits, with extra coverage to help you save even more. Look for participating providers with the
PLUS mark or visit one of the many online options.
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