Page 10 - Bar Bakers EE Guide 09-17 English Final

BENEFITS

VISION INSURANCE

EyeMed Vision Care | PPO Vision Plan
The EyeMed Vision Care vision plan provides professional vision care and high quality lenses and frames through a broad network of
optical specialists. You will receive richer benefits if you utilize a network provider. If you utilize a non‐network provider, you will be
responsible to pay all charges at the time of your appointment and will be required to file an itemized claim with EyeMed Vision Care.

EyeMed Vision Care
Plan Name PPO Plan

Network Name Select Non-Network
Vision Benefits
Copay
- Examination $25 Copay N/A
- Materials N/A N/A

Examination (Every 12 Months) No Charge $35 Reimbursement
Lenses (Every 12 Months)
- Single Vision No Charge $35 Reimbursement
- Bifocal No Charge $49 Reimbursement
- Trifocal No Charge $74 Reimbursement
- Standard Progressive $65 Copay $49 Reimbursement
- Premium Progressive $65 Copay, 80% of Charge Less $120 $49 Reimbursement
- Lenticular No Charge $74 Reimbursement
Lenses Options
- UV Treatment $15 Copay N/A
- Tint (Solid and Gradient) $15 Copay N/A
- Standard Plastic Scratch Coating $15 Copay N/A
- Standard Polycarbonate $40 Copay N/A
- Standard Polycarbonate (Kids Under 19) No Charge $28 Reimbursement
- Standard Anti-Reflective Coating $45 Copay N/A
- Polarized 20% Off Retail Price N/A
- Other Add-Ons and Services 20% Off Retail Price N/A
Frames (Every 12 Months) $130 Allowance, $65 Reimbursement
80% of Charge Over $130

Contact Lenses (Every 12 Months) In Lieu of Frames and Lenses
- Cosmetic / Elective $130 Allowance, $104 Reimbursement
15% off Balance Over $130
- Medically Necessary No Charge $200 Reimbursement
Laser Vision Correction Discounts Apply Not Covered

Note
The EyeMed network includes access to independent ophthalmologists and optometrists, as well as LensCrafters®, Target Optical,
Sears Optical, JCPenney Optical and most Pearle Vision retail stores.

Finding a Vision Provider
Go to www.eyemedvisioncare.com or call (866) 723-0513. Refer to the “Select” network when prompted.

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