Page 6 - Mi Health and Hospital 2021 Renewal Booklet.2

Michigan Health & Hospital Association: Vision Cost Analysis
Effective January 2021

Current Renewal
EyeMed EyeMed

12/12/12 12/12/12
with progressive enhancements with progressive enhancements

Rates Counts
Single 33 $7.02 $7.02
Two Person 37 $13.33 $13.33
Family 71 $19.57 $19.57
Estimated Monthly Premium $2,114.34 $2,114.34
Estimated Annual Premium $25,372.08 $25,372.08
Percentage Change 0.00%
Annual Dollar Change $0.00
In-Network In-Network
Frequency 12/12/12 12/12/12
Eye Exam $10 $10
Materials/Eyewear $0*/$25 $0*/$25
Allowance $150 $150

This is a summary analysis only. Refer to certificate of coverage for all specific details.
This summary is not a contract and makes no representations or warranties as to final outcomes of claim adjudication.
4 year rate guarantee from the effective date of 1/1/2020-12/31/2024
* $0 Copay on Frames and Contact Lenses $150 Allowance for each, $25 copay on Standard Lenses if not purchasing Contacts. See Benefit Summary.
Renewal includes Freedom Pass- Pay $0 for any frame at LensCrafters or Target Optical locations