Vision Plan for Louisiana State Employees

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 LENSESa,b (1 per 12 months)
  • Conventional (+15% discount over allowance)
    & Disposable (+balance over allowance)

  • Medically Necessary

  • Fit & Follow-up (2 follow-up visits)
    Standardc
    Premiumd

$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 CORRECTIONe,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 WorkerÂ’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

Louisiana State benefit enrollment and termination rules apply. Contact your benefits administrator for details.


To find a vision provider in your area, visit www.enrollwitheyemed.com/access and select the "Access" network from the dropdown box.