Page 12 - 2016 Enrollment
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Vision Plan
No change to the How the Plan Works
Monthly Vision If you use an EyeMed provider, the plan pays for an eye exam every 12
Premiums and Plan months, after you make a $15 copayment. You also receive a set allowance
Design for 2016 for frames every 24 months and a set allowance for contact lenses every 12
Vision Premiums months. The plan pays for lenses for prescription glasses every 12 months,
Eligibility Monthly Bi- after you pay a $25 copayment.
weekly
Options Rate Rate
Individual $5.10 $2.35 In addition, you can receive extra discounts, including:
Individual $9.69 $4.47
+ spouse Paying no more than $55 for a contact lens itting and evaluation
Individual $10.20 $4.71 15 percent off the regular price of laser vision correction or 5 percent off
+
child(ren) the promotional price from contracted facilities
Individual $15.00 $6.92 40 percent off a second, third, and fourth complete pair of eyeglass
+ family
purchases once the funded beneit has been used (includes prescription
sunglasses)
For more information about your vision beneits and to see a complete list of
member providers, visit www.eyemed.com.
Vision Benefits Plan Design
Vision Plan—starts in January
In-Network Out-of-Network Frequency
Eye exams $15 You are reimbursed Once every plan
up to $35 year
Prescription Glasses
Lenses
Single $25 You are reimbursed Once every plan
up to $25 year
Bifocal $25 You are reimbursed
up to $40
Trifocal $25 You are reimbursed
up to $60
Polycarbonate $40 N/A
Frames You receive a $150 allowance Once every two
for frames, plus a 20% You are reimbursed plan years
discount off any amount over up to $75
your allowance
Contact lenses— You receive a $125 allowance, Once every plan
conventional 15% off balance over $125 year
(materials only) You are reimbursed
Contact lenses— You receive a $125 allowance, Up to $100 Once every plan
disposable plus balance over $125 year
(materials only)
Thompson Coburn LLP
Vision Plan
No change to the How the Plan Works
Monthly Vision If you use an EyeMed provider, the plan pays for an eye exam every 12
Premiums and Plan months, after you make a $15 copayment. You also receive a set allowance
Design for 2016 for frames every 24 months and a set allowance for contact lenses every 12
Vision Premiums months. The plan pays for lenses for prescription glasses every 12 months,
Eligibility Monthly Bi- after you pay a $25 copayment.
weekly
Options Rate Rate
Individual $5.10 $2.35 In addition, you can receive extra discounts, including:
Individual $9.69 $4.47
+ spouse Paying no more than $55 for a contact lens itting and evaluation
Individual $10.20 $4.71 15 percent off the regular price of laser vision correction or 5 percent off
+
child(ren) the promotional price from contracted facilities
Individual $15.00 $6.92 40 percent off a second, third, and fourth complete pair of eyeglass
+ family
purchases once the funded beneit has been used (includes prescription
sunglasses)
For more information about your vision beneits and to see a complete list of
member providers, visit www.eyemed.com.
Vision Benefits Plan Design
Vision Plan—starts in January
In-Network Out-of-Network Frequency
Eye exams $15 You are reimbursed Once every plan
up to $35 year
Prescription Glasses
Lenses
Single $25 You are reimbursed Once every plan
up to $25 year
Bifocal $25 You are reimbursed
up to $40
Trifocal $25 You are reimbursed
up to $60
Polycarbonate $40 N/A
Frames You receive a $150 allowance Once every two
for frames, plus a 20% You are reimbursed plan years
discount off any amount over up to $75
your allowance
Contact lenses— You receive a $125 allowance, Once every plan
conventional 15% off balance over $125 year
(materials only) You are reimbursed
Contact lenses— You receive a $125 allowance, Up to $100 Once every plan
disposable plus balance over $125 year
(materials only)
Thompson Coburn LLP
