Page 23 - 2017 US Benefits Guide - for all Capgemni employees in the FS SBU
P. 23
Vision Plan Benefits (continued)
Vision Services Description In-Network Coverage Out-of-Network Coverage
Contact Lenses: Contact Lens allowance $10 co-payment, once every Reimbursed up to $200
includes materials only. Standard Contact Lens 12 months per covered member
it and follow-up is covered In-network up to Up to $200 allowance
$50 and Premium Contact Lens it and follow-up
is 10% of retail price.
Note: You cannot choose both contacts and
lenses and a frame as a covered beneit during
the same 12-month period.
2
Medically Necessary Contact Lenses : $0 co-pay, then covered in full Reimbursed up to $210 ,
3
Contact lenses determined medically-necessary per covered member
by the provider.
Refractive Eye Surgery: A surgical procedure Discounts available from Not covered
that can reduce a person’s dependency on U.S. Laser Network of 15% of
glasses or contact lenses. retail price or 5% of promotional
price, visit www.eyemed.com
2 Necessary contacts are determined at the provider’s discretion for one or more of the following conditions: following post cataract surgery
without intraocular lens implant; to correct extreme vision problems that cannot be corrected with spectacle lenses; with certain conditions
of anisometropia; with certain conditions of keratoconus. If your provider considers your contacts necessary, you should ask your provider
to contact EyeMed Vision concerning the reimbursement that EyeMed Vision will make before you purchase such contacts.
3 Receipts for services and materials purchased on diferent dates must be submitted together as part of a single claim to receive
reimbursement. Receipts must be submitted within 12 months of the date of service.
CAPGEMINI 2017 BENEFITS GUIDE 20
Vision Services Description In-Network Coverage Out-of-Network Coverage
Contact Lenses: Contact Lens allowance $10 co-payment, once every Reimbursed up to $200
includes materials only. Standard Contact Lens 12 months per covered member
it and follow-up is covered In-network up to Up to $200 allowance
$50 and Premium Contact Lens it and follow-up
is 10% of retail price.
Note: You cannot choose both contacts and
lenses and a frame as a covered beneit during
the same 12-month period.
2
Medically Necessary Contact Lenses : $0 co-pay, then covered in full Reimbursed up to $210 ,
3
Contact lenses determined medically-necessary per covered member
by the provider.
Refractive Eye Surgery: A surgical procedure Discounts available from Not covered
that can reduce a person’s dependency on U.S. Laser Network of 15% of
glasses or contact lenses. retail price or 5% of promotional
price, visit www.eyemed.com
2 Necessary contacts are determined at the provider’s discretion for one or more of the following conditions: following post cataract surgery
without intraocular lens implant; to correct extreme vision problems that cannot be corrected with spectacle lenses; with certain conditions
of anisometropia; with certain conditions of keratoconus. If your provider considers your contacts necessary, you should ask your provider
to contact EyeMed Vision concerning the reimbursement that EyeMed Vision will make before you purchase such contacts.
3 Receipts for services and materials purchased on diferent dates must be submitted together as part of a single claim to receive
reimbursement. Receipts must be submitted within 12 months of the date of service.
CAPGEMINI 2017 BENEFITS GUIDE 20
