EyeMed Vision
BENEFITS*
In Network
Out Of Network
Exams (every 12 months)
$20 copay
Plan Pays Up To $49
Vision Exam
Frames (every 24 months)
Plan pays up to $130 allowance, then 20% off amount over frame allowance 40% additional pair discount
Plan Pays Up To: $60
Frames
Plan Pays Up To: $200
Covered in Full
Medically Necessary Frames
Lenses (every 12 months)
Plan Pays Up To: $35 $49 $74
Single Bifocal Trifocal
$20 copay $20 copay $20 copay
Lens Options
$15 $40 $45
Tint/UV Coating/Scratch-Resistant Standard Polycarbonate Standard Anti-Reflective
Not Covered
Contact Lenses – In lieu of glasses (every 12 months)
Plan Pays up To: $104 $104 $200
Conventional Disposables Medically Necessary Fit & Follow-up (Standard/Premium)
$130 allowance, 15% off + $130 $130 allowance No charge Up to $55/10% off retail
Not Covered
Laser Vision Correction
15% of retail (or 5% of promotional)
Benefit
Not Covered
Sign up as a member online to print ID cards, locate providers through the Access network, and view benefits and claims. www.EyeMed.com
* Please refer to carrier booklet. Plan limits may apply. 26
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