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HomeMy WebLinkAboutEyeMed Benefit Summary.pdfOtay Water District SUMMARY OF BENEFITS VISION CARE SERVICES IN-NETWORK MEMBER COST OUT-OF-NETWORK MEMBER REIMBURSEMENT EXAM SERVICES Exam at PLUS Provider $0 copay Up to $40 Exam $10 copay Up to $40 Retinal Imaging Up to $39 Not covered CONTACT LENS FIT AND FOLLOW-UP Fit & Follow-up - Standard Up to $40; contact lens fit and two follow-up visits Not covered Fit & Follow-up - Premium 10% off retail price Not covered FRAME Frame at PLUS Provider $0 copay; 20% off balance over $180 allowance Up to $91 Frame $0 copay; 20% off balance over $130 allowance Up to $91 STANDARD PLASTIC LENSES Single Vision $25 copay Up to $30 Bifocal $25 copay Up to $50 Trifocal $25 copay Up to $70 Lenticular $25 copay Up to $70 Progressive - Standard $80 copay Up to $50 Progressive - Premium Tier 1 $110 copay Up to $50 Progressive - Premium Tier 2 $120 copay Up to $50 Progressive - Premium Tier 3 $135 copay Up to $50 Progressive - Premium Tier 4 $200 copay Up to $50 LENS OPTIONS Anti Reflective Coating - Standard $45 copay Up to $5 Anti Reflective Coating - Premium Tier 1 $57 copay Up to $5 Anti Reflective Coating - Premium Tier 2 $68 copay Up to $5 Anti Reflective Coating - Premium Tier 3 $85 copay Up to $5 Photochromic - Non-Glass $75 Not covered Polycarbonate - Standard $40 Not covered Polycarbonate - Standard < 19 years of age $0 copay Up to $5 Scratch Coating - Standard Plastic $15 Not covered Tint - Solid or Gradient $15 Not covered UV Treatment $15 Not covered All Other Lens Options 20% off retail price Not covered CONTACT LENSES Contacts - Conventional $0 copay; 15% off balance over $130 allowance Up to $91 Contacts - Disposable $0 copay; 100% of balance over $130 allowance Up to $91 Contacts - Medically Necessary $0 copay; paid-in-full Up to $210 OTHER Hearing Care from Amplifon Network Discounts on hearing exam and aids; call 1.877.203.0675 Not covered Lasik or PRK from U.S. Laser Network 15% off retail or 5% off promo price; call 1.800.988.4221 Not covered FREQUENCY (Plan allows member to receive either contacts and frame, or frame and lens services) Exam Once every plan year Frame Once every other plan year Lenses Once every plan year Save even more with PLUS Providers $50 Additional frame allowance from PLUS Providers* *Compared to $130 frame allowance at other EyeMed in-network providers Find an eye doctor (Insight Network) ·eyemed.com ·EyeMed Members App ·For LASIK, call 1.800.988.4221 Contacts Lenses Once every plan year QL-0000030667 EyeMed reserves the right to make changes to the products available on each tier. All providers are not required to carry all brands on all tiers. For current listing of brands by tier, call 866-939-3633. No benefits will be paid for services or materials connected with or charges arising from: medical or surgical treatment, services or supplies for the treatment of the eye, eyes or supporting structures; Refraction, when not provided as part of a Comprehensive Eye Examination; services provided as a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof; orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; any Vision Examination or any corrective Vision Materials required by a Policyholder as a condition of employment; safety eyewear; solutions, cleaning products or frame cases; non-prescription sunglasses; plano (non-prescription) lenses; plano (non-prescription) contact lenses; two pair of glasses in lieu of bifocals; electronic vision devices; services rendered after the date an Insured Person ceases to be covered under the Policy, except when Vision Materials ordered before coverage ended are delivered, and the services rendered to the Insured Person are within 31 days from the date of such order; or lost or broken lenses, frames, glasses, or contact lenses that are replaced before the next Benefit Frequency when Vision Materials would next become available. Fees charged by a Provider for services other than a covered benefit and any local, state or Federal taxes must be paid in full by the Insured Person to the Provider. Such fees, taxes or materials are not covered under the Policy. Allowances provide no remaining balance for future use within the same Benefit Frequency. Some provisions, benefits, exclusions or limitations listed herein may vary by state. Plan discounts cannot be combined with any other discounts or promotional offers. In certain states members may be required to pay the full retail rate and not the negotiated discount rate with certain participating providers. Please see online provider locator to determine which participating providers have agreed to the discounted rate. Underwritten by Fidelity Security Life Insurance Company of Kansas City, Missouri, except in New York. Fidelity Security Life Policy number VC-146, form number M-9184. This is a snapshot of your benefits. The Certificate of Insurance is on file with your employer.