Page 14 - Enrollment Guide
P. 14
Open
Enrollment
Vision
Coverage Vision
Find an In-Network Vision beneits are essential to maintaining your overall health and
Provider Today! well-being, which is why we are proud to offer vision coverage through
Finding a convenient vision EyeMed Vision Care. You can apply your beneit toward any eye exam,
care provider is easy. Visit available frame, or brand of contact lenses that it your lifestyle.
www.eyemedvisioncare.com and
choose the SELECT Network or call Covered Services In-network Out-of-network
1-866-299-1358 to locate a provider, Beneit Frequency
or contact your local leading optical Vision Examination (Once every $10 copay Up to $30
®,
retailer such as LensCrafters Target 12 months)
®,
Optical JCPenney Optical Sears Standard Contact (Once every Up to $40 N/A
®,
12 months)
Lens Fit and Follow
®,
Optical and most Pearle Vision® Up
locations. Eyeglass Frames (Once every No copay, $120 Up to $60
24 months) allowance, 20%
off retail price over
$120
Standard Lenses (Once every $25 copay Up to:
Single Vision/Bifocal/ 12 months) $25/$40/$60
Trifocal
Lenses Options $15 N/A
UV/Tint/Standard
Scratch coating
Polycarbonate/Anti- $40/$45/20% off N/A
Relective/Polarized retail price
Conventional (Once every No copay, $135 Up to $108
Contact Lenses (In 12 months) allowance, 15%
lieu of glasses) off retail price over
$135
Laser Vision 15% off retail N/A
Correction Lasik or price or 5% off
PRK from U.S. Laser promotional price
Network
This summary of beneits is intended to be a brief outline of coverage. The entire provisions
Need additional pairs of beneits and exclusions are contained in the Summary Plan Description (SPD). In the event
of eyeglasses or do you of a conlict between the SPD and this description, the terms of the SPD will prevail.
wear both eyeglasses and Weekly Contribution Rates
contacts? Employee $1.24
Members are eligible for a 40%
discount off an additional eyeglass Employee + Spouse $2.36
purchase and a 15% discount off Employee + Child(ren) $2.48
contacts once the funded Family $3.64
beneit has been
used.
14
Enrollment
Vision
Coverage Vision
Find an In-Network Vision beneits are essential to maintaining your overall health and
Provider Today! well-being, which is why we are proud to offer vision coverage through
Finding a convenient vision EyeMed Vision Care. You can apply your beneit toward any eye exam,
care provider is easy. Visit available frame, or brand of contact lenses that it your lifestyle.
www.eyemedvisioncare.com and
choose the SELECT Network or call Covered Services In-network Out-of-network
1-866-299-1358 to locate a provider, Beneit Frequency
or contact your local leading optical Vision Examination (Once every $10 copay Up to $30
®,
retailer such as LensCrafters Target 12 months)
®,
Optical JCPenney Optical Sears Standard Contact (Once every Up to $40 N/A
®,
12 months)
Lens Fit and Follow
®,
Optical and most Pearle Vision® Up
locations. Eyeglass Frames (Once every No copay, $120 Up to $60
24 months) allowance, 20%
off retail price over
$120
Standard Lenses (Once every $25 copay Up to:
Single Vision/Bifocal/ 12 months) $25/$40/$60
Trifocal
Lenses Options $15 N/A
UV/Tint/Standard
Scratch coating
Polycarbonate/Anti- $40/$45/20% off N/A
Relective/Polarized retail price
Conventional (Once every No copay, $135 Up to $108
Contact Lenses (In 12 months) allowance, 15%
lieu of glasses) off retail price over
$135
Laser Vision 15% off retail N/A
Correction Lasik or price or 5% off
PRK from U.S. Laser promotional price
Network
This summary of beneits is intended to be a brief outline of coverage. The entire provisions
Need additional pairs of beneits and exclusions are contained in the Summary Plan Description (SPD). In the event
of eyeglasses or do you of a conlict between the SPD and this description, the terms of the SPD will prevail.
wear both eyeglasses and Weekly Contribution Rates
contacts? Employee $1.24
Members are eligible for a 40%
discount off an additional eyeglass Employee + Spouse $2.36
purchase and a 15% discount off Employee + Child(ren) $2.48
contacts once the funded Family $3.64
beneit has been
used.
14
