Page 15 - QSC Benefit Summary 7-18 COLORADO

VISION INSURANCE

The Vision plan includes benefits for eye exams, eyeglasses, and contact lenses through EyeMed. You may visit a doctor
within the EyeMed SELECT network and take advantage of higher benefits coverage, or visit a non-network provider of
your choice for a reduced benefit.

EyeMed
Plan Features PPO
Network Name Select Non-Network
VISION BENEFITS You Pay Reimbursement

Deductible N/A N/A
Examination (Every 12 Months) $25 Copay Up to $35
Lenses (Every 12 Months)
Single Vision No Charge Up to $35
Bifocal No Charge Up to $49
Trifocal No Charge Up to $74
Standard Progressive $65 Copay Up to $49
Premium Progressive $65 Copay, $120 Allowance, Up to $49
then 80% Discount
Lenticular No Charge Up to $74
UV Treatment $15 Copay Not Covered
Tint (Solid and Gradient) $15 Copay Not Covered
Standard Plastic Scratch Coating No Charge Up to $11
Standard Polycarbonate $40 Copay Not Covered
Standard Polycarbonate (child under age 19) $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
then 20% Discount
Contact Lenses (Every 12 Months)
Elective $130 Allowance, Up to $104
then 15% Discount*
Necessary No Charge Up to $200
Laser Vision Correction 15% off Retail Price, or Not Covered
(Lasik or PRK from US Laser Network) 5% off Promotional Price
*Contact lenses discount does not apply toward disposable lenses.

FINDING A VISION PROVIDER:
The EyeMed SELECT network includes access to independent ophthalmologists and optometrists, as
well as LensCrafters®, Target Optical, Sears Optical, JCPenney Optical, OneRx and most Pearle Vision
retail stores.

Go to www.eyemedvisioncare.com or call (866) 723-0514 to find a provider near you. Refer to the
“Select” network when prompted.

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