Page 22 - 2017 US Benefits Guide - for all Capgemni employees in the FS SBU

Vision Plan Benefits

Vision Services Description In-Network Coverage Out-of-Network Coverage
Eye Exam: A complete initial vision analysis, $10 co-payment, once every Reimbursed up to $60,
which includes a comprehensive visual 12 months, per covered member per covered member
exam, including the prescription of corrective
eyewear, if necessary.

1
Single Lenses : Lenses having one part that $10 co-payment, once every Reimbursed up to $40,
corrects either near vision or distant vision. 12 months, per covered member per covered member
1
Bifocal Lenses : Lined lenses having one part $10 co-payment, once every Reimbursed up to $60,
that corrects near vision, one for distant vision. 12 months, per covered member per covered member
1
Trifocal Lenses : Lined lenses having one part $10 co-payment, once every Reimbursed up to $80,
that corrects near vision, one for intermediate 12 months, per covered member per covered member
vision, and one for distant vision.

1
Lenticular Lenses : Lenses designed to $10 co-payment, once every Reimbursed up to $80,
reduce weight and thickness, primarily used 12 months, per covered member per covered member
for post-cataract lenses.
Frames: The supporting structure of a pair of $10 co-payment, once every Reimbursed up to $200,
glasses that holds the lenses in place. 12 months per covered member
Note: When costs exceed the
$80 wholesale frame allowance or
$200 retail frame allowance, you
will be responsible for the diference
less a 20% to 40% discount

1 In-network lens options, such as progressive lenses, and anti-relective coating may be available at a Continued on next page
higher co-payment or at a discount.

CAPGEMINI 2017 BENEFITS GUIDE 19