Unified Fire Authority Benefit Guide (1)_ (003) | Page 21

Vision Benefits
Administered by EyeMed Network- Insight
Regular eye examinations can not only determine your need for corrective eyewear but also may detect general health problems in their earliest stages. Protection for the eyes should be a major concern to everyone. Members that choose Plus Providers enjoy additional benefit perks. You can find in network eye doctors – including PLUS Providers – on the Provider Locator at eyemed. com.
In-Network Member Cost At Plus Providers
In-Network( Member Cost)
Out-of-Network( Reimbursement)
Eye Exam— once every 12 months
$ 0 copay
$ 10 copay
Up to $ 40 allowance
Frames
Any available frame at provider location.
$ 0 copay: 20 % off balance over $ 180 allowance
$ 0 copay; 20 % off balance over $ 130 allowance
Up to $ 91 allowance
Lenses Single Vision Lenses
$ 25 copay
$ 25 copay
Up to $ 30 allowance
Bifocal Lenses
$ 25 copay
$ 25 copay
Up to $ 50 allowance
Trifocal Lenses
$ 25 copay
$ 25 copay
Up to $ 70 allowance
Lens Options UV Coating
$ 15
$ 15
N / A
Tint( Solid and Gradient)
$ 15
$ 15
N / A
Standard Plastic Scratch Coating
$ 15
$ 15
N / A
Standard Polycarbonate
$ 40
$ 40
N / A
Standard Anti-Reflective
$ 45
$ 45
N / A
Contacts
Conventional
Disposable
$ 0 copay: 15 % off balance over $ 130 allowance
$ 0 copay: 100 % of balance over $ 130 allowance
$ 0 copay; 15 % off balance over $ 130 allowance
$ 0 copay; 100 % of balance over $ 130 allowance
Up to $ 130 allowance
Up to $ 130 allowance
Medically Necessary
$ 0 copay; paid in full
$ 0 copay; paid in full
Up to $ 300 allowance
Frequency Examination
Once every 12 months
Frames
Once every 12 months
Lenses or Contact Lenses
Once every 12 months
For Lasik providers, call 877.5LASER6
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