Page 18 - QSC EE Guide 01-20 Colorado

EyeMed | Vision Plan
QSC provides vision coverage through EyeMed. You can see an EyeMed in-network provider or an out-of-network
provider, however, your costs will be lower if you visit an in-network provider. If you visit an in-network provider
you will be responsible for a copayment at the time of your service. If you receive services from an out-of-network
doctor, you will pay all costs at the time of service and submit a claim for reimbursement.

EyeMed
Plan Name PPO
Network Name Select Non-Network
Vision Benefits
Examination (Every 12 Months) $25 Copay Up to $35 Reimbursement
Lenses (Every 12 Months)
- Single Vision No Charge Up to $35 Reimbursement
- Bifocal No Charge Up to $49 Reimbursement
- Trifocal No Charge Up to $74 Reimbursement
- Standard Progressive $65 Copay Up to $49 Reimbursement
- Premium Progressive $65 Copay, $120 Allowance, Up to $49 Reimbursement
then 80% Discount
- Lenticular No Charge Up to $74 Reimbursement
Lens Enhancements
- UV Treatment $15 Copay Not Covered
- Tint (Solid and Gradient) $15 Copay Not Covered
- Standard Plastic Scratch Coating No Charge Up to $11 Reimbursement
- Standard Polycarbonate $40 Copay Not Covered
- Standard Anti-Reflective Coating $45 Copay Not Covered
- Polarized 20% Discount to Retail Not Covered
- Other Add-Ons and Services 20% Discount to Retail Not Covered
Frames (Every 12 Months) $130 Allowance, Up to $65 Reimbursement
then 20% Discount
Contact Lenses (Every 12 Months) (in lieu of frames and lenses)

- Cosmetic / Elective $130 Allowance, Up to $104 Reimbursement
then 15% Discount*
- Medically Necessary No Charge Up to $200 Reimbursement
Laser Vision Correction 15% off Retail Price, or Not Covered
(Lasik or PRK from US Laser Network) 5% off Promotional Price
*Contact lens discount does not apply toward disposable lenses

Finding a Vision Provider
Go to www.eyemedvisioncare.com. Refer to the “Select” network

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.