Page 13 - 2016 Open Enrollment
P. 13
Pericient, Inc.
National retailers include but not limited
Vision Insurance to:
JC Penney Optical
Vision beneits are offered through EyeMed vision care. You have LensCrafters
the lexibility to visit network or non-network doctors; however, you
will pay more out-of-pocket costs for those providers that are out-of- Pearle Vision
network. Sears Optical
The following chart summarizes the key features of the plans. Target Optical
Refer to the Summary Plan Description for additional details about For a complete listing of providers
coverage and exclusions. log onto the EyeMed website at
www.eyemedvisioncare.com.
EyeMed—Vision
In-Network Out-of-Network
Copay
Exam $10 copay Up to $15
Lenses
Single $25 copay Up to $5
Bifocal $25 copay Up to $15
Trifocal $25 copay Up to $33
Lenticular $25 copay Up to $33
Frames
Frames $130 retail allowance plus Up to $65
20% discount on overage
Contacts *
Elective $130 retail allowance Up to $104
Medically necessary $0 copay Up to $200
Frequency
Exam 12 months
Lenses 12 months
Contacts (in lieu of 12 months
glasses)
Frames 24 months
* Contact lens evaluation and itting is subject to a $25 copay
Employee Contributions per Pay Period Vision
Employee Only $1.43
Employee + Spouse $2.72
Employee + Child(ren) $2.87
Employee + Family $4.21
13
National retailers include but not limited
Vision Insurance to:
JC Penney Optical
Vision beneits are offered through EyeMed vision care. You have LensCrafters
the lexibility to visit network or non-network doctors; however, you
will pay more out-of-pocket costs for those providers that are out-of- Pearle Vision
network. Sears Optical
The following chart summarizes the key features of the plans. Target Optical
Refer to the Summary Plan Description for additional details about For a complete listing of providers
coverage and exclusions. log onto the EyeMed website at
www.eyemedvisioncare.com.
EyeMed—Vision
In-Network Out-of-Network
Copay
Exam $10 copay Up to $15
Lenses
Single $25 copay Up to $5
Bifocal $25 copay Up to $15
Trifocal $25 copay Up to $33
Lenticular $25 copay Up to $33
Frames
Frames $130 retail allowance plus Up to $65
20% discount on overage
Contacts *
Elective $130 retail allowance Up to $104
Medically necessary $0 copay Up to $200
Frequency
Exam 12 months
Lenses 12 months
Contacts (in lieu of 12 months
glasses)
Frames 24 months
* Contact lens evaluation and itting is subject to a $25 copay
Employee Contributions per Pay Period Vision
Employee Only $1.43
Employee + Spouse $2.72
Employee + Child(ren) $2.87
Employee + Family $4.21
13
