Page 14 - 2016 Nortek Enrollment Guide COBRA
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Vision beneits are essential to Vision Care
maintaining your overall health and
well-being. Our vision care coverage
is through EyeMed, and includes Out-Of-Network
beneits for in-network and out of In-Network “Member” Costs Reimbursement
network care. Eye exam $10 copay Up to $30
You can apply your vision beneits Contact Lens it and follow-up
toward any eye exam, any available Standard $0 copay, plus 2 covered follow up Up to $40
frames, or brand of contact lenses that visits at no charge to the employee
it your lifestyle. Premium $0 copay, 10% off retail price, then Up to $40
apply $55 allowance
How to Find a Vision Frames
Provider $0 copay, $130 allowance; 20% off Up to $40
balance over $130
Visit www.eyemedvisioncare.com Standard Plastic Lenses (tinting and/or coating not covered)
and select the Insight Network. Single vision $25 copay Up to $15
Bifocal $25 copay Up to $30
Trifocal $25 copay Up to $45
Lenticular $25 copay Up to $45
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% off Up to $130
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.
Nortek
Vision beneits are essential to Vision Care
maintaining your overall health and
well-being. Our vision care coverage
is through EyeMed, and includes Out-Of-Network
beneits for in-network and out of In-Network “Member” Costs Reimbursement
network care. Eye exam $10 copay Up to $30
You can apply your vision beneits Contact Lens it and follow-up
toward any eye exam, any available Standard $0 copay, plus 2 covered follow up Up to $40
frames, or brand of contact lenses that visits at no charge to the employee
it your lifestyle. Premium $0 copay, 10% off retail price, then Up to $40
apply $55 allowance
How to Find a Vision Frames
Provider $0 copay, $130 allowance; 20% off Up to $40
balance over $130
Visit www.eyemedvisioncare.com Standard Plastic Lenses (tinting and/or coating not covered)
and select the Insight Network. Single vision $25 copay Up to $15
Bifocal $25 copay Up to $30
Trifocal $25 copay Up to $45
Lenticular $25 copay Up to $45
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% off Up to $130
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.
Nortek
