Page 14 - Ampact 2022 Benefit Guide

Vision Insurance

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
coverage through EyeMed offers a robust network of independent providers,
along with additional discounts at LensCrafters, Pearle Vision, and Target
Optical.

*As a reminder, HealthPartners still covers one annual eye exam

Benefit In-Network PLUS Insight Network Out-of-Network
Providers*

Frequency
Lenses 12 months 12 months 12 months
Frames 24 months 24 months 24 months
Exam 12 months 12 months 12 months
Eye Exam $0 $10 Up to $40

Frames $0 copay; 20% off $0 copay; 20% off balance Up to $91
balance over $180 over $130
Lenses
Single vision lenses Up to $30
Bifocal lenses Up to $50
Trifocal lenses $25 copay $25 copay Up to $70
Lenticular Up to $70

Medically necessary contact Covered in full after Covered in full after copay Up to $210
lenses copay

Elective contact lenses in lieu $130 allowance $130 allowance Up to $91
of glasses
40% off additional pairs of glasses and a 15% discount on conventional lenses once
funded benefit is used – an industry exclusive

Additional Discounts 20% off any item not covered by the plan, including non-prescription sunglasses
Hearing Care
Amplifon Hearing Health Care Network 40% off hearing exams and a low-price
guarantee on discounted hearing aids

Vision Rates Per Pay Period
Employee $3.35
Employee + Spouse/DP $6.36
Employee + Child(ren) $6.69
Family $9.84

*In-Network PLUS Providers: LensCrafters, Target Optical, & Pearle Vision

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Effective August 1, 2022-July 31, 2023