Page 23 - 2018 Capgemini Enrollment
P. 23
Voluntary 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
(Limit to one co-payment for materials, i.e.,
lenses and frames.)
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
(Limit to one co-payment for materials, i.e.,
lenses and frames.)
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. (Limit to
one co-payment for materials, i.e., lenses and
frames.)
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. (Limit to one co-
payment for materials, i.e., lenses and frames.)
Frames: The supporting structure of a pair of $10 co-payment, once every Reimbursed up to $200,
glasses that holds the lenses in place. (Limit to 12 months per covered member
one co-payment for materials, i.e., lenses and Note: When costs exceed the
frames.) $200 retail frame allowance,
you will be responsible for the
diference less a 30% discount
1 Lenses purchased in-network with standard scratch-resistant coating and polycarbonate lenses are covered in full. Other in-network lens
options, such as progressive lenses, tints, UV, and anti-reflective coating, may be available at a discount.
Continued on next page
CAPGEMINI 2018 BENEFITS GUIDE 20
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
(Limit to one co-payment for materials, i.e.,
lenses and frames.)
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
(Limit to one co-payment for materials, i.e.,
lenses and frames.)
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. (Limit to
one co-payment for materials, i.e., lenses and
frames.)
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. (Limit to one co-
payment for materials, i.e., lenses and frames.)
Frames: The supporting structure of a pair of $10 co-payment, once every Reimbursed up to $200,
glasses that holds the lenses in place. (Limit to 12 months per covered member
one co-payment for materials, i.e., lenses and Note: When costs exceed the
frames.) $200 retail frame allowance,
you will be responsible for the
diference less a 30% discount
1 Lenses purchased in-network with standard scratch-resistant coating and polycarbonate lenses are covered in full. Other in-network lens
options, such as progressive lenses, tints, UV, and anti-reflective coating, may be available at a discount.
Continued on next page
CAPGEMINI 2018 BENEFITS GUIDE 20
