Page 15 - SC Fuels Benefit Guide 2018 TEXAS
P. 15

VOLUNTARY VISION





            AMERITAS | PPO VISION PLANS
            The Ameritas Vision plans provide professional vision care and high quality lenses and frames through a broad
            network of optical specialists. You may choose between the EyeMed Access network and the VSP network. The
            EyeMed network includes access to private practice and optical retail locations, including LensCrafters®, Target
            Optical, Sears Optical, JCPenney Optical and Pearle Vision. VSP provides you access to the largest network of
            individual practitioners. With both network plans, if you utilize a non-network provider, you will be responsible
            to pay all of the charges at the time of your appointment, and you will be required to file an itemized claim with
            Ameritas. You may access your vision plan by providing your eye doctor with your social security number (your
            dependents will need to provide your social security number). Please note, ID cards will not be provided and are
            not needed to use the plan.


                                                          Ameritas                          Ameritas
                                                  EyeMed Access Network                   VSP Network
             Network Name                         Network       Non-Network         Network       Non-Network
             VISION BENEFITS
             Deductible                                     $25                                $25
             Examination (Every 12 Months)       $10 Copay      $35 Allowance      $10 Copay      $52 Allowance
             Lenses (Pair) (Every 12 Months)
             •   Single Vision                   No Charge      $25 Allowance      No Charge      $55 Allowance
             •   Bifocal                         No Charge      $40 Allowance      No Charge      $75 Allowance
             •   Trifocal                        No Charge      $55 Allowance      No Charge      $95 Allowance
             Frames (Every 12 Months)          $130 Allowance   $65 Allowance    $130 Allowance   $70 Allowance
             Contact Lenses (Every 12 Months)    (in lieu of frames and lenses)    (in lieu of frames and lenses)
             •   Cosmetic / Elective           $130 Allowance  $104 Allowance    $130 Allowance   $105 Allowance
             Employee Rate Per Paycheck
             •   Employee Only                              $4.02                             $5.78
             •   Employee + 1                               $7.66                            $10.96
             •   Employee + 2 or More                      $11.34                             $16.10


                     FINDING A VISION PROVIDER:

                     •   EyeMed Access Network: Visit www.ameritas.com. Click “Find a Provider” and choose Vision:
                        EyeMed Access Plan Network.
                     •   VSP Network: Visit www.ameritas.com. Click “Find a Provider” and choose Vision: VSP.






















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