Page 14 - Sample Calendar Layout EE Guide

EyeMed Vision Plan
ABC Company provides vision coverage through EyeMed Vision through the Select network. 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 and 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’ll pay all costs at the time of service and submit a claim for
reimbursement. You will receive a separate vision ID card.

Kaiser Medical plan members: The Kaiser HMO plan has a pediatric vision benefit for children to age 19 that covers lenses and frames once every 12
months.

PLAN NAME EYEMED PPO

NETWORK NAME SELECT NETWORK NON-NETWORK

Exam
Once Every 12 Months $0 Copay Up to $35 reimbursement
Lenses
Once every 12 months
Single Vision $25 Copay Up to $35 reimbursement
Bifocal $25 Copay Up to $49 reimbursement Additional Discounts Available
Trifocal $25 Copay Up to $74 reimbursement LASIK and PRK Benefit: You are entitled to a 15% discount
on the usual and customary fees for LASIK and PRK
Frames procedures, or a 5% discount on any promotional pricing,
Once every 24 months $130 Allowance Up to $65 reimbursement whichever is the greater benefit, through the U.S. Laser
Network.
Contact Lenses (in lieu of glasses)
Once every 12 months $130 Allowance Up to $96 reimbursement Continued Eyewear Savings: After your initial visits have
been utilized, you are able to receive ongoing discounts
on additional eye wear purchases at EyeMed provider
locations, 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 to find a provider near you. Refer to Contact Lens by Mail Program: You may order
the Select network when prompted. replacement contact lenses at competitive prices via the
internet by visiting www.eyemedcontacts.com. This
The EyeMed network includes access to independent ophthalmologists service is for replacement contact lenses only. Your initial
and optometrists, as well as LensCrafters®, Target Optical, Sears Optical, pair of contact lenses must still be purchased from your
JCPenney Optical, and most Pearle Vision retail stores. eye care provider to ensure proper fit and follow up care.