Page 12 - QSC Benefits Guide 7-17 CALIFORNIA A

VISION INSURANCE

The Vision plan includes benefits for eye exams, eyeglasses, and contact lenses through EyeMed. You may visit a doctor
within the EyeMed SELECT network and take advantage of higher benefits coverage, or visit a non-network provider of
your choice for a reduced benefit.

EyeMed
Plan Features PPO
Network Name Select Non-Network
VISION BENEFITS You Pay Reimbursement

Deductible N/A N/A N/A
Examination Every 12 Months $25 Copay Up to $35
Lenses Every 12 Months
Single Vision No Charge Up to $35
Bifocal No Charge Up to $49
Trifocal No Charge Up to $74
Standard Progressive $65 Copay Up to $49
Frames Every 12 Months $130 Allowance, then 20% Up to $65
Discount
Contact Lenses Every 12 Months
Elective $130 Allowance, Up to $104
then 15% Discount*
Necessary No Charge Up to $200
*Contact lenses discount does not apply toward disposable lenses.

FINDING A VISION PROVIDER:
The EyeMed SELECT network includes access to independent ophthalmologists and optometrists, as
well as LensCrafters®, Target Optical, Sears Optical, JCPenney Optical, OneRx and most Pearle Vision
retail stores.

Go to www.eyemedvisioncare.com or call (866) 723-0514 to find a provider near you. Refer to the
“Select” network when prompted.

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