VISION INSURANCE
Fast Track Urgent Care offers vision coverage through Aetna. The Aetna vision plan allows you the flexibility to see any provider. To search in-network providers vision www.Aetna.com and search in the “Your Network Name”. You pay expenses at the time of service and file a claim for reimbursement. Below is a list of the reimbursement schedule.
VSP Choice Network
In-Network Routine Eye Exams
Every 12 months $__ Copay
Lenses 2
Every 12 months
Single Vision Bifocal Trifocal Lenticular
$__ Copay
Frames
Every 12 months
$__ Copay provides a $xxx allowance PLUS xx% off cost over the allowance
Contact Lenses (in lieu of glasses)
Every 12 months
Elective Contact Lenses Preferred Non-Preferred
$__ Copay provides up to x boxes $__ Copay provides a $xxx allowance
Medically Necessary
$__ Copay
Out-of-Network 1
Routine Eye Exams
Every 12 months Reimbursed up to $XXX Every 12 months Reimbursed up to $XXX Reimbursed up to $XXX Reimbursed up to $XXX Reimbursed up to $XXX Every 12 months Reimbursed up to $XXX
Lenses 2 Single Bifocal
Trifocal Lenticular
Frames
Contact Lenses (in lieu of glasses)
Every 12 months Reimbursed up to $XXX Reimbursed up to $XXX Bi-Weekly Cost for Coverage
Employee Only
$
Employee + Spouse
$
Employee + Child(ren)
$
Employee + Family
$
1 Reimbursable amount, less applicable copay.
2 Lenses benefit listed are for a pair of lenses.
5
Made with FlippingBook Online newsletter