VISION PLAN COMPARISON CHART
In Network Benefits
The EyeMed Access Network
includes such familiar names as Lenscrafters®,
Pearle Vision®,
Sears Optical,
and Target Optical®,
along with
thousands of independent optometrists, ophthalmologists and opticians.
| EYE EXAMINATION |
| Frequency |
Once every 12 months |
Once every 12 months |
Once every 12 months |
| Insureds Co-pay |
None |
$10 |
$10 |
| EYEGLASS LENSES |
| Frequency |
Once every 24 months |
Once every 12 months |
Once every 24 months |
| Insureds Co-pay |
None |
$10 |
$20 |
| FRAMES |
| Frequency |
Once every 24 months |
Once every 12 months |
Once every 24 months |
| Insureds Co-pay |
None |
$0 |
$0 |
| CONTACTS (in lieu of eyeglass lenses) |
| Frequency |
Same as eyeglass lenses |
Same as eyeglass lenses |
Same as eyeglass lenses |
| Insureds Co-pay |
Same as eyeglass lenses |
Same as eyeglass lenses |
Same as eyeglass lenses |
Out of Network Benefits
The greatest benefit is
realized when network providers are used, but members may choose out of
network providers, paying the provider and receiving reimbursement from the
plan according to the schedule below. Call the toll-free number for a claim
form.
| EYE EXAMINATION |
| We Pay Up To |
$30 |
$25 |
$25 |
| FRAMES |
| We Pay up To |
$40 |
$40 |
$40 |
| EYEGLASS LENSES - single vision |
| We Pay Up To |
$25 |
$20 |
$20 |
| EYEGLASS LENSES - bifocal |
| We Pay up To |
$45 |
$40 |
$30 |
| EYEGLASS LENSES - trifocal |
| We Pay Up To |
$55 |
$50 |
$40 |
| CONTACTS (in lieu of eyeglass lenses) |
| We Pay up To |
$75 |
$70 |
$60 |
WHAT THE BENEFITS INCLUDE:
Eye Examination
- A routine, complete eye examination, refraction, and prescription for
eyeglasses. Contact lens examinations require additional fees. If indicated,
your doctor may recommend additional procedures, which are the
responsibility of the member.
Eyeglass Lenses
- Standard uncoated plastic lenses of any size or power.
Frames
- Any frame up to a regular retail value of $100. Frames above $100 retail
are available at an additional charge.
Contact Lenses
- Any pair of contact lenses up to a regular retail price of $100. Obtained
from a network provider or the mail order program. Contacts above $100 are
available at an additional charge.
ADDITIONAL BENEFITS (In Network Only) LENS OPTIONS (add to lens prices above)
| Add-Ons |
Co-Payment |
Add-Ons |
Co-Payment |
| UV Coating |
$15 |
Tint |
$15 |
| Scratch Resistance |
$15 |
Polycarbonate |
$40 |
| Anti-Reflective |
$45 |
Standard Progressive |
$65 |
| Other Add Ons |
20% Retail Discount |
|
LASIK – NON-INSURED
DISCOUNT BENEFIT
The
EyeMed Access network provides discounts to insureds interested in LASIK – A
LASER VISION CORRECTION PROCEDURE. This non-insured benefit is offered at
savings of 15% off the regular retail price or 5% off the promotional price
when using the network.
UNDERWRITING GUIDELINE
- Rates are guaranteed for a period of TWO YEARS from the effective date
- Full-time students up to age 25 are eligible as dependents
- Annual open enrollment
STATE RESTRICTIONS
| State |
Limitation |
| Connecticut |
Not Available |
| New Hampshire |
Not Available |
| New Jersey |
Not Available |
| New York |
Not Available |
| Vermont |
Not Available |
| Washington |
Not Available |
The agent has no authority to grant CPT or to waive the waiting period provision of the Plan. The GemStar Dental Plan benefit waiting periods will apply to all individuals not insured under the employer's prior dental plan and to all individuals insured after the employer's Initial Effective Date
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