Rates

VISION RATES PER PAY PERIOD
(Assumes 24 pay periods)

BASIC ENHANCED

EMPLOYEE ONLY $4.24 $5.16

EMPLOYEE & 1 DEPENDENT $7.91 $9.59

EMPLOYEE & FAMILY $11.38 $13.58

Summary of Covered Benefits

BASIC PLAN ENHANCED PLAN

EyeMed In-Network Out-of-Nework EyeMed In-Network Out-of-Nework

EXAM(1 per 12 months) $4 co-pay $30 $4 co-pay $30

Frames(1 per 12 months) $100 allowance, 20%
off balance over $100 $45 $150 allowance, 20% off
balance over $150 $45

STANDARD PLASTIC LENSES(1 per 12 months)

Single Vision

Bifocal

Trifocal

Progressive

Lenticular

$10 co-pay
$10 co-pay
$10 co-pay
$10 co-pay
$10 co-pay
$20
$40
$40
$40
$100
$10 co-pay
$10 co-pay
$10 co-pay
$10 co-pay
$10 co-pay
$30
$45
$65
$65
$105

LENS OPTIONS:

UV Coating

Tint (Solid and Gradient)

Standard Scratch-Resistance

Standard Polycarbonate

Standard Anti-Reflective Coating

Other Add-Ons and Services

$15
$15
$15
$40
$45
20% off retail
N/A
N/A
N/A
N/A
N/A

$15
$15
$15
$40
$45
20% off retail
N/A
N/A
N/A
N/A
N/A

CONTACT LENSES^a,b (1 per 12 months)

Conventional (+15% discount over allowance)
& Disposable (+balance over allowance)

Medically Necessary

Fit & Follow-up (2 follow-up visits)
Standard^c
Premium^d

$0 co-pay & $75
allowance

Paid in full

Up to $55
10% off retail
$75
$75

$150

N/A
N/A
$0 co-pay & $110
allowance

Paid in full

Up to $55
10% off retail
$110
$110

$210

N/A
N/A

LASER VISION CORRECTION^e,f
(once per lifetime per eye)
Lasik or PRK 15% off retail price or 5% off promotional price N/A $125 allowance per eye + 15% off retail price or 5% off promotional price $125 allowance per eye

a Contact Lenses in lieu of eyeglass lenses

b Contact Lens allowance is a one-time use allowance per benefit year

c Standard Contact Lens Fitting-spherical clear contact lenses in conventional wear and planned replacement

(Examples include but not limited to disposable, frequent replacement, etc.)

d Premium Contact Lens Fitting-all lens designs, materials and specialty fittings other than the Standard Contact Lenses (Examples include toric, multifocal, etc.)

e Laser vision benefit in lieu of all other covered benefits

f Members receive discount from the U.S. Laser Network, owned and operated by LCA Vision.

Summary of Limitations & Exclusions

This plan will not cover:

Orthoptic or vision training, subnormal vision aids, and any associated supplemental testing

Medical and/or surgical treatment of the eye, eyes, or supporting structures

Services provided as a result of any Worker’s Compensation law

Benefit is not available on certain frame brands in which the manufacturer imposes a no discount policy

Corrective eyewear required by an employer as a condition of employment, and safety eyewear unless specifically covered under plan

Plano non-prescription lenses and non-prescription sunglasses (except for 20% discount)

Services or materials provided by any other group benefit providing for vision care

Two pairs of glasses in lieu of bifocals

Aniseikonic lenses

To find a vision provider in your area, visit www.enrollwitheyemed.com/access

VISION RATES PER PAY PERIOD (Assumes 24 pay periods)
	BASIC	ENHANCED
EMPLOYEE ONLY	$4.24	$5.16
EMPLOYEE & 1 DEPENDENT	$7.91	$9.59
EMPLOYEE & FAMILY	$11.38	$13.58

	BASIC PLAN		ENHANCED PLAN
	EyeMed In-Network	Out-of-Nework	EyeMed In-Network	Out-of-Nework

	a		Contact Lenses in lieu of eyeglass lenses
	b		Contact Lens allowance is a one-time use allowance per benefit year
	c		Standard Contact Lens Fitting-spherical clear contact lenses in conventional wear and planned replacement
			(Examples include but not limited to disposable, frequent replacement, etc.)
	d		Premium Contact Lens Fitting-all lens designs, materials and specialty fittings other than the Standard Contact Lenses (Examples include toric, multifocal, etc.)
	e		Laser vision benefit in lieu of all other covered benefits
	f		Members receive discount from the U.S. Laser Network, owned and operated by LCA Vision.