Page 12 - Benefits Guide

Employee Benefits Guide
Vision Coverage
This plan helps pay for a wide range of vision-related services and products, including periodic eye exams, eyeglasses and contact lenses for you and your covered dependents.
You have a choice of two vision care options provided through MetLife, which has a large network of vision care providers. You can check if your provider is in the network at www.metlife.com/vision. Services and supplies are covered once every 12 months unless otherwise noted.
Paying for Coverage
You’ll pay the cost of vision coverage with before-tax dollars. How much you pay is based on the dependents you cover. You can enroll any combination of you, your spouse, and your children in the option you choose.
Provider: MetLife
Vision Base Plan
Vision Buy-Up Plan
In-Network
Out-of-Network
In-Network
Out-of-Network
Routine Vision Exam
$20 copay
once every 12 months
$45 allowance
$10 copay
once every 12 months
$45 allowance
Frames
$100 allowance
once every 24 months
$55 allowance
$200 allowance
once every 12 months
$70 allowance
Lenses
Single vision
$20 copay
once every 12 months
$30 allowance
$10 copay
once every 12 months
$30 allowance
Lined bifocal
$50 allowance
$50 allowance
Lined trifocal
$65 allowance
$65 allowance
Lenticular
$100 allowance
$100 allowance
Lens Enhancements
Ultraviolet coating
$17–$33 copay
Not covered
$10 copay
Not covered
Polycarbonate
(child up to age 18)
Scratch-resistant coating Tints and dyes
Average 20–25% savings on other lens enhancements
Progressive Lenses
Standard
$55 copay
$50 allowance
$55 copay
$50 allowance
Premium
$95–$105 allowance
$95–$105 allowance
Custom
$150–$175 copay
$150–$175 copay
Contact Lenses - once every 12 months
Fitting and evaluation
$60 copay
Cost applied to allowance
$60 copay
Cost applied to allowance
Elective
$100 allowance
$80 allowance
$200 allowance
$105 allowance
Medically Necessary
$20 copay
$210 allowance
$10 copay
$210 allowance
Note: Additional discounts and savings may apply on additional pairs of glasses and sunglasses, as well as laser vision correction services from participating facilities.
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