Vision Care Plan
Covered Expenses and Plan Payment
Your Vision Care Plan will pay for covered vision care expenses only. To be considered a covered expense, any vision care service that you or an eligible dependent receives must be:
- provided by a licensed physician, optometrist, or dispensing optician who is operating within the scope of his or her license; and
- required for the covered person’s visual health and welfare, as indicated by a vision examination.
The Plan does not cover:
- services provided by an unlicensed provider; or
- other services listed in the Exclusions and Limitations section.
| If you are not sure whether a given vision care service is covered by the Plan, you can contact EyeMed Member/Patient Services at 1-877-829-5067. You can also visit the EyeMed Vision Care website at www.eyemedvisioncare.com for more information. |
EYEGLASSES: LENSES AND FRAMES
The Plan covers the cost of eyeglass lenses once every 12 months for each covered person. The Plan also covers the cost of frames once every 24 months.
| Benefit | In-Network Cost | Out-of-Network Reimbursement |
| Frames (any available frame at provider location) |
|
Up to $114 |
| Standard Plastic Lenses | ||
| Single Vision | $25 copay | Up to $42 |
| Bifocal | $25 copay | Up to $78 |
| Trifocal | $25 copay | Up to $130 |
| Lenticular | $25 copay | Up to $130 |
| Standard Progressive Lens | $90 copay | Up to $78 |
| Premium Progressive Lens | $90 copay, plus 80% of Charge less $120 allowance* | Up to $196 |
| Lens Options | ||
| UV Treatment | $15 | N/A |
| Tint (solid and gradient) | $15 | N/A |
| Standard Plastic Scratch Coating | $0 | Up to $12 |
| Standard Polycarbonate – Adults | $40 | N/A |
| Standard Polycarbonate – Children under age 19 | $0 | Up to $26 |
| Standard anti-reflective Coating | $45 | N/A |
| Polarized | 20% off retail price | N/A |
| Other add-ons | 20% off retail price | N/A |
*For example, assume that the total cost of your premium progressive lens is $320. 80% x $320 = $256; $256 less $120 allowance = $136; $136 + $90 copay = $226 (your total out-of-pocket cost)
You can contact EyeMed Vision Care Member/Patient Services at 1-877-829-5067 or visit their website at www.eyemedvisioncare.com for more information on benefits for eyeglasses, including network provider discounts.
CONTACT LENSES
The Plan covers the cost of contact lenses (materials only) once every 12 months for each covered person.
| Benefit | In-Network Cost | Out-of-Network Reimbursement |
|
Conventional Contact Lenses |
|
Up to $144 |
|
Disposable Contact Lenses |
|
Up to $144 |
| Medically Necessary Contact Lenses | Covered 100% (no copay) | Up to $200 |
| After initial purchase, discounted replacement contact lenses may be purchased online and mailed directly to you. | ||
You can contact EyeMed Vision Care Member/Patient Services at 1-877-829-5067 or visit their website at www.eyemedvisioncare.com for more information on benefits for contact lenses, including network provider and replacement lens discounts.
LASER VISION CORRECTION
The Plan covers LASIK or PRK laser vision correction that is provided through the U.S. Laser Network. There is no out-of-network coverage for laser vision correction.
Benefits for in-network laser vision correction are provided at:
- 15% off the retail price; or
- 5% off the promotional price
You can contact EyeMed Vision Care at 1-877-5LASER6 or visit their website at www.eyemedlasik.comfor more information on:
- participating laser vision correction providers; and
- the steps you should follow to obtain your discount.
ADDITIONAL PAIRS BENEFIT
The Plan covers the purchase of additional complete pairs of eyeglasses or conventional contact lenses, provided that the original eyeglasses or contact lenses were purchased using your EyeMed benefits. In this case, the Plan provides:
- a 40% discount for additional eyeglass purchases; and
- a 15% discount for additional contact lens purchases.
You can contact EyeMed Vision Care Member/Patient Services at 1-877-829-5067 or visit their website at www.eyemedvisioncare.com for more information on the additional pairs benefit.
ADDITIONAL BENEFITS
EyeMed members may be eligible for discounts on additional vision care materials that are not otherwise covered by the Plan. You can contact your network provider for more information about any available discounts for EyeMed members.
