Page 12 - 2020 BH Management Benefits Guide
P. 12
Avesis Vision Coverage
Policy #10771-1457 We partner with Avesis to offer you and your family members vision
Plan #133 insurance. Visit www.avesis.com to ind in-network providers and access
www.avesis.com to a variety of online tools and programs.
800.828.9341
In-Network Out-of-Network
Copay
Exam $10 Up to $35 reimbursement
Materials $15 Reimbursement varies
Lenses
Single Covered in full Up to $25 reimbursement
Bifocal Covered in full Up to $40 reimbursement
Trifocal Covered in full Up to $50 reimbursement
Lenticular Covered in full Up to $80 reimbursement
Progressive $50 allowance plus up to Up to $40 reimbursement
20% of retail
Frames Up to $150 allowance Up to $45 reimbursement
Contacts
Medically Necessary Covered in full Up to $250 reimbursement
Elective $130 allowance Up to $130 reimbursement
Beneit Applies to Adults and children
LASIK
Up to $150 reimbursement
Frequency
Exam 12 months
Lenses 12 months
Contacts (in lieu 12 months
of glasses)
Frames 24 months
This is a high level summary of your beneit coverage. Full coverage
details are available in your summary plan description (SPD). In the event
there is a discrepancy between what is relected in this guide and what is
communicated in your SPD, the terms of your SPD will prevail.
Contributions
Monthly Cost Per Pay Period
Employee $6.03 $3.02
Employee and Spouse $11.38 $5.69
Employee and Child(ren) $11.82 $5.91
Family $15.96 $7.98
12 2020 Benefits Guide
Policy #10771-1457 We partner with Avesis to offer you and your family members vision
Plan #133 insurance. Visit www.avesis.com to ind in-network providers and access
www.avesis.com to a variety of online tools and programs.
800.828.9341
In-Network Out-of-Network
Copay
Exam $10 Up to $35 reimbursement
Materials $15 Reimbursement varies
Lenses
Single Covered in full Up to $25 reimbursement
Bifocal Covered in full Up to $40 reimbursement
Trifocal Covered in full Up to $50 reimbursement
Lenticular Covered in full Up to $80 reimbursement
Progressive $50 allowance plus up to Up to $40 reimbursement
20% of retail
Frames Up to $150 allowance Up to $45 reimbursement
Contacts
Medically Necessary Covered in full Up to $250 reimbursement
Elective $130 allowance Up to $130 reimbursement
Beneit Applies to Adults and children
LASIK
Up to $150 reimbursement
Frequency
Exam 12 months
Lenses 12 months
Contacts (in lieu 12 months
of glasses)
Frames 24 months
This is a high level summary of your beneit coverage. Full coverage
details are available in your summary plan description (SPD). In the event
there is a discrepancy between what is relected in this guide and what is
communicated in your SPD, the terms of your SPD will prevail.
Contributions
Monthly Cost Per Pay Period
Employee $6.03 $3.02
Employee and Spouse $11.38 $5.69
Employee and Child(ren) $11.82 $5.91
Family $15.96 $7.98
12 2020 Benefits Guide
