Page 15 - Nortek California Employee Guide
P. 15
Nortek
Vision Care
In-Network “Member” Costs Out-Of-Network Vision Care
Reimbursement
Eye Exam $10 copay Up to $30 Vision beneits are essential to
Contact Lens it and follow-up maintaining your overall health and
Standard $0 copay, plus 2 covered follow Up to $40 well-being . Our vision care coverage is
up visits at no charge to the through EyeMed, and includes beneits
employee for in-network and out of network care .
Premium $0 copay, 10% off retail price, Up to $40
then apply $55 allowance You can apply your vision beneits
Frames toward any eye exam, any available
$0 copay, $130 allowance; 20% Up to $40 frames, or brand of contact lenses that
off balance over $130 it your lifestyle.
Standard Plastic Lenses
Single vision $25 copay Up to $15 How to Find a Vision
Bifocal $25 copay Up to $30 Provider
Trifocal $25 copay Up to $45 Visit www.eyemedvisioncare.com
Lenticular $25 copay Up to $45 and select the Insight Network .
Standard Progressive $25 copay Up to $45
Premium Progressive $45-70 copay Up to $45
(Tier 1-3)
Premium Progressive $25 copay 80% of charge less Up to $45
(Tier 4) $120 allowance
Contact Lenses (allowance covers materials only)
Conventional $0 copay, $130 allowance; 15% Up to $130
off balance over $130
Disposables $0 copay, $130 allowance Up to $130
Medically necessary $0 copay; paid in full Up to $210
LASIK and PRK 15% off retail price or 5% off N/A
promotional pricing
Frequency Limits
Exam Once every twelve months
Frames Once every twenty four months
Lenses or Contact Once every twelve months
Lenses
Please refer to your Summary Plan Description (SPD) for complete details of plan beneits,
limitations, and exclusions. In the event of a conlict between the SPD and this description,
the terms of the SPD will prevail .
15
Vision Care
In-Network “Member” Costs Out-Of-Network Vision Care
Reimbursement
Eye Exam $10 copay Up to $30 Vision beneits are essential to
Contact Lens it and follow-up maintaining your overall health and
Standard $0 copay, plus 2 covered follow Up to $40 well-being . Our vision care coverage is
up visits at no charge to the through EyeMed, and includes beneits
employee for in-network and out of network care .
Premium $0 copay, 10% off retail price, Up to $40
then apply $55 allowance You can apply your vision beneits
Frames toward any eye exam, any available
$0 copay, $130 allowance; 20% Up to $40 frames, or brand of contact lenses that
off balance over $130 it your lifestyle.
Standard Plastic Lenses
Single vision $25 copay Up to $15 How to Find a Vision
Bifocal $25 copay Up to $30 Provider
Trifocal $25 copay Up to $45 Visit www.eyemedvisioncare.com
Lenticular $25 copay Up to $45 and select the Insight Network .
Standard Progressive $25 copay Up to $45
Premium Progressive $45-70 copay Up to $45
(Tier 1-3)
Premium Progressive $25 copay 80% of charge less Up to $45
(Tier 4) $120 allowance
Contact Lenses (allowance covers materials only)
Conventional $0 copay, $130 allowance; 15% Up to $130
off balance over $130
Disposables $0 copay, $130 allowance Up to $130
Medically necessary $0 copay; paid in full Up to $210
LASIK and PRK 15% off retail price or 5% off N/A
promotional pricing
Frequency Limits
Exam Once every twelve months
Frames Once every twenty four months
Lenses or Contact Once every twelve months
Lenses
Please refer to your Summary Plan Description (SPD) for complete details of plan beneits,
limitations, and exclusions. In the event of a conlict between the SPD and this description,
the terms of the SPD will prevail .
15
