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EyeMed Network Plan

EyeMed offers one of the largest vision networks in the nation with When members visit an EyeMed network provider they'll save:
a mix of independent providers and retail chains. Find EyeMed • 20% off remaining frame balance
network providers at eyemed.com. • 40% off non-covered complete prescription glasses
• special pricing on lens upgrades such as UV coating &
PEARLE polycarbonate lenses & 20% off non-covered materials
LENSCRAFTERS" .. ,.OQ= (!}OPTICAL: • 15% average off retail price for LASIK or PAK laser vision
VISION
correction, or 5% off promotional price, at U.S Laser
contactsd i rect GLASSES.�. Network locations

Based on applicable laws, reduced costs may vary by doctor location.
What the plans pay in-network/ out-of-network
Deductible Choose between $10 exam & $25 materials OR $15 exam & $15 materials
Annual eye exam 100% I Up to $35
Single vision 100% I Up to $25
Bifocal 100% I Up to $40
Trifocal 100% I Up to $55

Contacts $130 / Up to $104
Benefit frequencies
Exam-lens-frame 12-12-24 12-12-12
Monthly rates

Employee $7.92 $8.64
Employee + spouse $17.08 $18.64
Employee + child(ren) $13.84 $15.08
Family $22.96 $25.08

Employee $8.24 $8.96
Employee + spouse $18.24 $19.88
Employee + child(ren) $14.84 $16.20
Family $24.88 $27.12
All rates are valid for policies with an effective date through 12/31/22, and are guaranteed for four years.
Voluntary plans may be set to align with the Section 125 plan year.
Limitations
Please refer to the CEJ@cate of Insurance for a complete fist of covered procedures. Check for avallablllty • Re�acement of specle lenses, frames, ancllor contact lenses furnished under this plan that are lost
In your state. Covered expenses l'.111 not lndude, and no benefits will be re}'e for: or CEmaged, except at the normal Intervals v.ilen sel\ices are othEJwlse avallatle.
• Visloo examinations, lenses and frames more thm the frequency as Indicated a, the plan summwy page. • Medical or SU'Qlcal treabnet1t of the eyes.
• Cxthoptk:s or lislcrl training and any assoclatoo supplemental testing. • Plans not avallalle In RI.
• Plano lenses Oenses with refrctive correction of less tiha plus a minus .50 clopte� except as • Plans are notavallable In R. for grou� with less than 51 lives.
speclflcally allowe In the frames benefit section of the Plan Benefits. • Spedflc plans not fisted In this ttocllJre are available for MA , MT. ME and MD.
• Two pairs of glasses In lieu of bifocals. Coosult yoor sales representa regarding �n avallablllty In the states of MA, WA and MD.

Ameritas�

fulfilling life.

'Not all providers at Costco locations are VSP network providers. Please verify that your provider Is In the VSP network before seeking services. The frame allowance at some retailers may be less due
to lower wholesale pricing.
This Is not a certificate of Insurance or guarantee of coverage. Plan designs may not be avallable In all areas and are subject to Individual state regulations. This piece Is not for use In New Mexico. This
Information Is providd by Amerttas Ufe Insurance Corp. (Ameritas Life). Dental, vision and hearing care products (9000 Rev. 03-16for Group and 9000 Rev. 02-19 for lndlvldual, dates may vary by state) are
Issued by Ameritas Life. The Dental and Vision Networks are not avallable In RI. In Texas, our dental network and plans are referred to as the Amerltas Dental Network. Ameritas, the bison design, "fulfllllng life"
are service marks or registered service marks of Amerltas Life, afflllaoo Amerltas Holding Company or Amerltas Mutual Holding Company. Cl 2021 Amerltas Mutual Holding Company.
IJ }# m! @ D @ I 800-776-9446 I ameritas.com