eyemed-summary.pdf

Pinellas County Board of Commissioners

SUMMARY OF BENEFITS

VISION CARE

SERVICES

IN-NETWORK

MEMBER COST

OUT-OF-NETWORK

MEMBER REIMBURSEMENT

EXAM SERVICES

Exam $10 copay Up to $40 Retinal Imaging Up to $39 Not covered

CONTACT LENS FIT AND FOLLOW-UP

Fit & Follow-up - Standard $0 copay Up to $40 Fit & Follow-up - Premium $0 copay; 10% off retail price, then apply

$40 allowance Up to $40

FRAME

Frame $0 copay; 20% off balance over $130 allowance Up to $50

STANDARD PLASTIC LENSES

Single Vision $20 copay Up to $40 Bifocal $20 copay Up to $60 Trifocal $20 copay Up to $80 Lenticular $20 copay Up to $100 Progressive - Standard $70 copay Up to $60 Progressive - Premium Tier 1 $100 copay Up to $60 Progressive - Premium Tier 2 $110 copay Up to $60 Progressive - Premium Tier 3 $125 copay Up to $60 Progressive - Premium Tier 4 $195 copay Up to $60

LENS OPTIONS

Anti Reflective Coating - Standard $35 copay Up to $5 Anti Reflective Coating - Premium Tier 1 $47 copay Up to $5 Anti Reflective Coating - Premium Tier 2 $58 copay Up to $5 Anti Reflective Coating - Premium Tier 3 $85 copay Up to $5

Photochromic - Non-Glass $65 copay Not covered

Polycarbonate - Standard $30 copay Up to $5 Polycarbonate - Standard < 19 years of age $0 copay Up to $5 Scratch Coating - Standard Plastic $0 copay Up to $5 Tint - Solid or Gradient $0 copay Up to $5 UV Treatment $12 copay Up to $5

High Index $55 copay Up to $5 All Other Lens Options 20% off retail price Not covered

CONTACT LENSES

Contacts - Conventional $0 copay; 15% off balance over $100 allowance Up to $100

Contacts - Disposable $0 copay; 100% of balance over $100 allowance

Up to $100

Contacts - Medically Necessary $0 copay; paid-in-full Up to $225

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 calendar year Frame Once every calendar year Lenses Once every calendar year Contacts Lenses Once every calendar year

40%OFF

additional complete pair of prescription eyeglasses

20%OFF

non-covered items, including non -prescription sunglasses

Find an eye doctor (Insight Network)

• eyemed.com

• EyeMed Members App

• For LASIK, call 1.800.988.4221

Heads up You may have additional benefits.

Log into eyemed.com/member to see all plans included with your benefits.

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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.

https://eyemed.com/member https://eyemed.com