Page 11 - Hitachi Benefit Guide 1.31.2019

Vision Plan

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

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

Hitachi Solutions America Employee Benefits Guide | 2019 11