Page 17 - Hitachi Benefits Booklet Final

PPO Vision Plan | EyeMed
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.

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.

Vision Plan EyeMed Vision

Network Name Select Network Non-Network

Vision Benefits
Copay
Examination $15 Copay $15 Copay
Materials $25 Copay $25 Copay
Examination (Every 12 Months) 100% Up to $35 Reimbursement
Lenses - (Every 12 Months)
Single 100% Up to $35 Reimbursement
Bifocal 100% Up to $49 Reimbursement
Trifocal 100% Up to $74 Reimbursement

Frames (Every 12 Months) $200 Allowance, then 80% Up to $100 Reimbursement
Contact Lenses
Elective (In lieu of frames & lenses) $200 Allowance, then 85% Up to $160 Reimbursement
Medically Necessary 100% Up to $200 Reimbursement
Laser Vision Correction
Lasik or PRK from US 15% Retail Discount Not Covered
Laser Network 5% Promotional Discount

Additional Discounts Available
LASIK and PRK Benefit: You are entitled to a 15% discount on the usual and customary fees for LASIK
and PRK procedures, or a 5% discount on any promotional pricing, whichever is the greater benefit,
through the US Laser Network.

Continued Eyewear Savings: After your initial visits have been utilized, you are able to receive ongoing
discounts on additional eye wear purchases at a network provider, which result in discounts up to 40%
off the retail price of eye wear and accessories.

Finding a Vision Provider
Go to www.eyemedvisioncare.com or call (866) 939-3633. Refer to the Select
network when prompted.