Vision

EyeMed

ABOUT VISION

Vision insurance provides coverage for routine eye examinations and can help with covering some of the costs for eyeglass frames, lenses or contact lenses.

For full plan details, please visit your benefit website: www.mybenefitshub.com/goosecreekcisd

EMPLOYEE BENEFITS

VISION CARE IN-NETWORK OUT-OF-NETWORK

SERVICES MEMBER COST MEMBER REIMBURSEMENT

EXAM SERVICES Exam Retinal Imaging CONTACT LENS FIT AND FOLLOW-UP Fit & Follow-up - Standard

Fit & Follow-up - Premium $10 copay Up to $39

Up to $40; contact lens fit and two follow-up visits 10% off retail price Up to $45 Not covered

Not covered

Not covered

FRAME Frame $0 copay; 20% off balance over $180 allowance Up to $126

STANDARD PLASTIC LENSES Single Vision Bifocal Trifocal Lenticular Progressive - Standard Progressive - Premium Tier 1 - 4 $10 copay $10 copay $10 copay $10 copay $65 copay $95-185 copay

LENS OPTIONS Anti Reflective Coating - Standard $45 copay Up to $23 Anti Reflective Coating - Premium Tier 1-3 $57 - 85 copay Photochromic - Non-Glass $75

Polycarbonate - Standard

$40 Polycarbonate - Standard < 19 years of age $0 copay Scratch Coating - Standard Plastic Tint - Solid and Gradient $15 $15

UV Treatment $15 Up to $30 Up to $50 Up to $70 Up to $70 Up to $50 Up to $50

Up to $23 Not covered Not covered Up to $20 Not covered Not covered Not covered

All Other Lens Options 20% off retail price Not covered

CONTACT LENSES Contacts - Conventional Contacts - Disposable Contacts - Medically Necessary $0 copay; 15% off balance over $180 allowance Up to $126 $0 copay; 100% of balance over $180 allowance Up to $126 $0 copay; paid-in-full Up to $210

OTHER Hearing Care from Amplifon Network Discounts on hearing exam and aids; call 1.877.203.0675 Lasik or PRK from U.S. Laser Network 15% off retail or 5% off promo price; call 1.800.988.4221

Not covered

Not covered Vision Employee $8.72 Employee + Spouse $18.64 Employee + Child(ren) $18.14 Family $27.48

FREQUENCY Exam Frame Lenses Contacts Lenses ALLOWED FREQUENCY –ADULTS Once every plan year Once every plan year Once every plan year Once every plan year

ALLOWED FREQUENCY –KIDS Once every plan year Once every plan year Once every plan year Once every plan year Visit https://eyedoclocator.eyemedvisioncare.com/ or call (866) 939-3633 to find an in-network vision provider.