Page 12 - 360 Behavioral Health Guide 2018-2019 Final

Vision Benefits

EyeMed | PPO Vision Plan
The EyeMed 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.

EyeMed
Plan Type:
PPO Plan

Network Type: In-Network Out of Network

Vision Benefits

Copay
- Examination (Every 12 Months) $10 Copay Reimbursed up to $40

Lenses (Every 12 Months)
− Single Vision $10 Copay Reimbursed up to $30
− Bifocal $10 Copay Reimbursed up to $50
− Trifocal $10 Copay Reimbursed up to $70
− Lenticular $10 Copay Reimbursed up to $70

Frames (Every 12 Months) $0 Copay, $180 allowance, 20% off balance over Reimbursed up to $126

Contact Lenses (Every 12 Months) In Lieu of Frames and Lenses

− Conventional $0 Copay, $180 allowance, 15% off balance over Reimbursed up to $180
− Medically Necessary $0 Copay, Paid-In-Full Reimbursed up to $210

Laser Vision Correction 15% off retail price or 5% off promotion price N/A

*For per pay period costs, please refer to page 16

Note: EyeMed has the largest network of private-practice eye care doctors in the industry. EyeMed’s network includes
37,000 access points nationwide. Most of the U.S. population lives within four miles of an EyeMed provider.

Finding In-Network Vision Providers
Go to www.eyemed.com or call (866) 804-0982

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