Page 12 - 5.11 Benefit Guide 2018 CA PRINT

VISION

The EyeMed Vision plan provides professional vision care and high quality lenses and frames through a broad network of
optical specialists. You will receive richer benefits if you utilize a network provider. If you utilize a non-network provider,
you will be responsible to pay all of the charges at the time of your appointment and you will be required to file an itemized
claim with EyeMed.

EYEMED
PPO PLAN
NETWORK NETWORK NON-NETWORK
VISION BENEFITS

Copay
• Examination $10 Copay None
• Materials $25 Copay None
Examination (Every 12 Months) 100% $35 Reimbursement
Lenses (Every 12 Months)
• Single Vision 100% $35 Reimbursement
• Bifocal 100% $49 Reimbursement
• Trifocal 100% $74 Reimbursement
Frames (Every 24 Months) $130 Allowance $65 Reimbursement
Contact Lenses (Every 12 Months) (in lieu of frames and lenses)
• Cosmetic / Elective $130 Allowance $104 Reimbursement
• Medically Necessary No Charge $200 Reimbursement
Laser Vision Correction Discounts Apply Not Covered

FINDING A VISION PROVIDER:
The EyeMed Vision network includes access to over 50,000 providers nationwide at over 30,000
locations, with a choice of independent and retail providers, as well as LensCrafters, Pearle Vision,
Sears Optical and Target Optical retail stores.

Go to www.eyemedvisioncare.com to find an EyeMed Select Network provider near you. Please refer
to the Select network when prompted.

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