Page 12 - Kate Somerville Benefits Guide 2020 NonCA

VISION & DENTAL

Vision Plan Choices

EYEMED | VISION PLAN
Kate Somerville provides vision coverage through EyeMed Vision. 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 Vision
Plan Name PPO
Network Name In-Network Non-Network
Vision Benefits
Copay
- Examination (Every 12 Months) $10 Copay Up to $40 Reimbursement
- Materials No Charge N/A
Lenses (Every 12 Months)
- Single Vision No Charge Up to $30 Reimbursement
- Bifocal No Charge Up to $50 Reimbursement
- Trifocal No Charge Up to $70 Reimbursement
Frames (Every 12 Months) $150 Benefit + 20% off balance Up to $105 Reimbursement
Contact Lenses (Every 12 Months) (in lieu of lenses)
- Cosmetic / Elective $150 Benefit + 15% off balance Up to $150 Reimbursement
- Medically Necessary No Charge Up to $210 Reimbursement
Laser Vision Correction Discounts Apply Not Covered

Cost Per Pay Period (24 per year)
- Employee $1.81
- Employee + spouse $5.06
- Employee + child(ren) $5.43
- Employee + family $8.82

VISION VALUE-ADDS
• Members will receive a 20% discount on remaining balance at partic-
FINDING A VISION PROVIDER:
ipating providers beyond plan coverage; this does not pertain to
disposable contacts.
Log on to www.enrollwitheyemed.com and • Save 15% off the retail price or 5% off the promotional price for
choose SELECT from the provider locater LASIK or PRK procedures.
dropdown box. You can also call
866-939-3633 • Discounts on hearing aids and exams through Amplifon
• With Sun Perks through EyeMed, you'll receive $20 off any purchase,
or $50 off a purchase of $200 or more toward premium, non-
prescription sunglasses at Sunglass Hut (some limitations apply, see
the flyer on the benefits website for more details).
12 KATE SOMERVILLE EMPLOYEE BENEFITS