Page 8 - 2016 Enrollment

Open Enrollment

Vision

Vision Coverage

Voluntary vision coverage for 2016 will continue to be offered
through EyeMed. Vision coverage is a voluntary beneit.

Beneit Level
In-Network Out-of-Network Frequency
Exam
$15 copay Up to $30 Every 12 months
Prescription Glasses *
Lenses (includes $15 copay for Up to $60 Every 12 months
single, lined, bifocal, materials
lined trifocal, and
lenticular lenses)
Standard $80 Up to $40 Every 12 months
Progressive Lenses
Premium $80 plus 80% of Up to $40 Every 12 months
Progressive Lenses charge less $120
allowance
Frames $100 allowance, Up to $50 Every 24 months
20% off retail
price above $100
Contact Lenses *
Conventional $100 allowance, Up to $80 Every 12 months
15% off retail
price above $100
Disposable $100 allowance, Up to $80 Every 12 months
plus balance
over $100
Medically necessary Covered at Up to $200 Every 12 months
100%

* Must choose either glasses or contacts

Your 2016 semi-monthly contributions for vision coverage are shown
below.

EyeMed Vision Plan
Employee only $2.82
Employee + 1 $5.35
Family $7.86

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