Page 12 - Benefits Summary/New Hire Enrollment Guide

Voluntary Vision

Nancy Bisson Joy Hebert
Northern will continue to offer the DeltaVision Voluntary Vision Plan (EyeMed Network) benefit to those
employees working 20+ hours per week. Employees are eligible for voluntary vision insurance on the first of
the month following 60 days of employment.

Please note If you are on the Northeast Delta Dental plan, you are offered a retail discount through EyeMed
which is simply a small discount off of retail prices. Much of the time the stores run promotions that are
better than the discount.

The discount is not of value to those with the fully insured DeltaVision plan because the DeltaVision plan
allows a 40% discount off any prescription glasses purchased outside of the network. That is a better value
than what you can get on the Dental EyeMed discount.

You cannot use the DeltaVision plan and the Dental Eyemed discount together.

A rate table with a breakdown of your pre-tax contribution for the 2020 – 2021 plan year, and a plan overview
are outlined below.

Weekly Rates Employee Employee + One Family
Deductions $1.33 $2.29 $4.09
Bi-Weekly Rates
Deductions $2.66 $4.57 $8.17

DeltaVision Plan Summary

Network Benefit Non-Network Reimbursement

Exam every 12 months Member pays $20; plan pays balance $35
Standard Contact Lens Fit/Follow-up Member pays up to $55 None
Premium Contact Lens Fit/Follow-up 10% discount off retail None
Frames every 24 months: (any $130 allowance, then 20% off balance $65
available frame at provider location)
Standard Plastic Lenses every 12 months

Single/Bifocal/Trifocal Member pays $20; plan pays balance $25/$40/$55
Lens Options
UV coating/Tint/Standard scratch
Member pays $15 each None
resistance
Standard polycarbonate Member pays $40 None

Standard anti-reflective coating Member pays $45 None
Standard progressive Member pays $85 None

12