Page 15 - 2016 Benefit Booklet AYN

Page 15

Voluntary Vision Benefits

Provided by Ameritas (EyeMed Network)

Frequency of Service: Copayment:
Exam Every 12 months Exam $10
Materials Materials $10 applies to lenses and
frames only
Lenses Every 12 months
Frames Every 12 months
Contact Lenses Every 12 months
Benefit after Copay In-Network Out-of-Network

Comprehensive Exam- Covered in Full Covered up to $50
Ophthalmologist (MD)

Comprehensive Exam- Covered in Full Covered up to $50

Standard Lenses: $10 Copay Covered up to $25

Bifocal Lenses $10 copay Covered up to $40

Trifocal Lenses $10 copay Covered up to $55

Lenticular Lenses 20% Discount No Benefit
Frames-Standard** Up to $130 Covered up to $65

Contact Lenses:*
Medically Necessary Covered in Full Covered up to $200

Cosmetic-Elective** Up to $130 Covered up to $104

*Contact Lenses are in lieu of eyeglass lenses & frames.
**The member is responsible for paying any charges in excess of this
allowance.
 Dependent children can be covered until the age of 26, regardless of student
status.
Employees per pay period cost (pre-tax) for plan year 10/1/16 to 9/30/17

Employee Only $3.27
Emp + Spouse $6.22
Emp + Child(ren) $6.55
Emp + Family $9.64