Page 13 - CPSS Benefit Guide Class 3 Employee

Vision plan

EyeMed

The vision plan provides coverage for routine eye exams and pays for all or a portion of the cost of glasses or contact
lenses. You can choose any provider; however, you always save money if you see in-network providers.

Vision Plan
Plan Provisions
In-Network Out-of-Network Reimbursement
Exam $10 copay Up to $40
$0 copay; $130 allowance; 20% balance
Frames Up to $91
over $130
Lenses
•Single vision lenses $25 copay Up to $30
•Bifocal lenses $25 copay Up to $50
•Trifocal lenses $25 copay Up to $70
Standard Progressive Lens $80 copay Up to $50
Premium Progressive Lens $110-$200 copay
Tier 1 $110 copay Up to $50
Tier 2 $120 copay Up to $50
Tier 3 $135 copay Up to $50
Tier 4 $200 copay Up to $50
Lenticular $25 copay Up to $70
Lens Options (paid by member and added
to the base price of the lens)
UV Treatment, Tint, Scratch Coating $15 N/A
Standard Polycarbonate $40 N/A
Standard Anti-Reflective $45 Up to $5
Premium Anti-Reflective $57-$85 N/A
Tier 1 $57 Up to $5
Tier 2 $68 Up to $5
Tier 3 $85 Up to $5
Photochromic/Transitions $75 N/A
Polarized 20% off retail N/A
Other Add-ons and Services 20% off retail N/A
Contact Lenses
$0 copay; $130 allowance; 15% off
Conventional Up to $130
balance over $130
$0 copay; $130 allowance; plus balance
Disposable Up to $130
over $130
Medically Necessary $0 copay, paid in full Up to $210
Frequency
Examination Once every 12 months
Lenses or Contact Lenses Once every 12 months
Frame Once every 24 months
To find a provider participating in your
vision plan network, visit eyemed.com
or call 1-866-804-0982

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