C2MB

Plan Name	Vision Materials Only
Description	All Employees
Carrier	EyeMed Vision Care
Policy Type	Vision
Effective Dates	8/1/2021 to 8/1/2022
Benefit Attributes - All Employees	In-Network	Out-of-Network
Benefit Frequency
Examination	Not covered	Not covered
Lenses	Once every plan year	Once every plan year
Frames	Once every other plan year	Once every other plan year
Contacts	Once every plan year	Once every plan year
Contact Lenses
Medically Necessary	$0 Copay, Paid-in-Full	Up to $210 reimbursement
Elective	Conventional:$0 Copay; $130 allowance,15% off balance over $130; Disposable: $0 Copay; $130 allowance, employee pays balance over $130	Up to $130 reimbursement
Copay
Examination	Not covered	Not covered
Materials	$20 copay	Up to $30 for single; Bifocal: Up to $50; Trifocals & Lenticular: Up to $70 (reimbursement)
Covered Services
Frames	$0 Copay; $130 Allowance 20% off balance over $130	Up to $91 reimbursement