Page 16 - GESMN 2019 Benefits Enrollment Guide

Vision

Vision Benefits

Eligible employees working 20 or more hours per week may elect Vision coverage.
Your eyes are the only place in your body which can provide a clear view of your
blood vessels, arteries and a cranial nerve which can tell your doctor a lot about
your overall health. This is why GESMN partners with EyeMed to offer you

vision insurance. The vision plan helps you pay for eye exams, eyeglasses (lenses
and frames) and contact lenses. The plan includes both in-network and out-of-
network benefits. EyeMed has more than 56,000 in-network providers, including
retail chains like LensCrafters, Pearle Vision, Target Optical and Sears Optical. To
locate an in-network provider, visit eyemedvisioncare.com or call 866-723-0513.

Vision Benefits At-a-Glance
In-Network Out-of-Network
Exams Covered in full, after $10 Up to $30
(every 12 months) copayment
Standard Contact Lens Fit & Up to $40 NA
Follow Up
Premium Contact Lens Fit & 10% off NA
Follow Up
Lenses (every 12 months)
Single $15 copay Up to $25
Bifocal $15 copay Up to $40
Trifocal $15 copay Up to $60
Lenticular $15 copay Up to $60
Approved Frames (every 12 months)
$150 allowance; 20% off Up to $65
balance
Approved Contact Lenses (every 12 months in lieu of glasses)
Elective—Conventional or $150 allowance; 15% off Up to $104
Disposable balance
Medically Necessary Covered in full Up to $210

2019 Vision Plan Premiums

Bi-Weekly
Employee Only $3.06
Employee and Spouse $5.83
Employee and Child(ren) $6.13
Employee and Family $9.02

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