Page 16 - 2016 Enrollment
P. 16
Open Enrollment
Vision Coverage
Vision
Vision beneits are essential to maintaining your overall health and
well-being, which is why we are proud to offer vision coverage
through EyeMed Vision Care. You can apply your beneit toward any
eye exam, available frame, or brand of contact lenses which it your
lifestyle.
Covered Services In-Network Out-of-Network
Beneit Frequency
Vision examination (Once every $10 copay Up to $30
12 months)
Standard contact (Once every Up to $40 N/A
lens it and follow 12 months)
up
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
Need additional pairs UV/tint/standard
of eyeglasses or do you scratch coating
wear both eyeglasses and Polycarbonate/Anti- $40/$45/20% off N/A
contacts? Relective/Polarized retail price
Members are eligible for a 40 percent Conventional (Once every No copay, $135 Up to $108
discount off an additional eyeglass contact lenses (in 12 months) allowance, 15%
purchase and a 15 percent discount off lieu of glasses) off retail price
contacts once the funded beneit has been over $135
used. Laser vision 15% off retail N/A
correction Lasik or price or 5% off
PRK from U.S. Laser promotional price
Network
Find an In-Network Provider
Today! This summary of beneits is intended to be a brief outline of coverage. The entire
provisions of beneits and exclusions are contained in the Summary Plan Description (SPD).
Finding a convenient vision care provider In the event of a conlict between the SPD and this description, the terms of the SPD will
prevail.
is easy. Visit www.eyemedvisioncare.com
and choose the SELECT Network or call Weekly Contribution Rates
866.299.1358 to locate a provider, or Employee $1.28
contact your local leading optical retailer Employee + spouse $2.55
®,
such as LensCrafters Target Optical ®, Employee + child(ren) $2.43
®,
JCPenney Optical Sears Optical and Family $3.75
®,
most Pearle Vision locations.
®
16
Vision Coverage
Vision
Vision beneits are essential to maintaining your overall health and
well-being, which is why we are proud to offer vision coverage
through EyeMed Vision Care. You can apply your beneit toward any
eye exam, available frame, or brand of contact lenses which it your
lifestyle.
Covered Services In-Network Out-of-Network
Beneit Frequency
Vision examination (Once every $10 copay Up to $30
12 months)
Standard contact (Once every Up to $40 N/A
lens it and follow 12 months)
up
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
Need additional pairs UV/tint/standard
of eyeglasses or do you scratch coating
wear both eyeglasses and Polycarbonate/Anti- $40/$45/20% off N/A
contacts? Relective/Polarized retail price
Members are eligible for a 40 percent Conventional (Once every No copay, $135 Up to $108
discount off an additional eyeglass contact lenses (in 12 months) allowance, 15%
purchase and a 15 percent discount off lieu of glasses) off retail price
contacts once the funded beneit has been over $135
used. Laser vision 15% off retail N/A
correction Lasik or price or 5% off
PRK from U.S. Laser promotional price
Network
Find an In-Network Provider
Today! This summary of beneits is intended to be a brief outline of coverage. The entire
provisions of beneits and exclusions are contained in the Summary Plan Description (SPD).
Finding a convenient vision care provider In the event of a conlict between the SPD and this description, the terms of the SPD will
prevail.
is easy. Visit www.eyemedvisioncare.com
and choose the SELECT Network or call Weekly Contribution Rates
866.299.1358 to locate a provider, or Employee $1.28
contact your local leading optical retailer Employee + spouse $2.55
®,
such as LensCrafters Target Optical ®, Employee + child(ren) $2.43
®,
JCPenney Optical Sears Optical and Family $3.75
®,
most Pearle Vision locations.
®
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