Page 10 - McKenzie 2022 Benefit Guide SD Salary

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. We offer vision coverage through MetLife.

MetLife Vision Plan

Plan Provisions In-Network Out-of-Network
Exam $10 copay Up to $40.00

2
$25 copay
Frames Up to $45.00
(Covered 100% up to $130 maximum)
Lenses
2
 Single Vision Lenses $25 copay Up to $40.00
2
 Bifocal Lenses $25 copay Up to $60.00
2
 Trifocal Lenses $25 copay Up to $80.00
 Lenticular Lenses $25 copay Up to $80.00
2
Contact Lenses
 Elective $25 copay Up to $125.00
3
Covered contact lens selection only
 Medically Necessary $25 copay Up to $210.00

Frequency
 Exam Every 12 months Every 12 months
1
 Lenses Every 12 months Every 12 months
1
 Frames Every 24 months Every 24 months
1
 Contact Lenses Every 12 months Every 12 months
1. Please note that you are eligible to select only one of either eyeglasses (lenses and/or frames) or contact lenses.
If you select more than one of these services in a calendar year, only one will be covered.
2. If you purchase lenses and frames at the same time from an in-network provider, only one copay will apply.
3. You may choose to purchase from your in-network provider contact lenses that are outside of the covered contact lens selection.
Non-selection contact lenses will receive an allowance of $125.00. No copay will apple to non-selection contact lenses.

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