C2MB

Plan Name	Vision Exam and Materials
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
Lenses	Once every plan year	Once every plan year
Examination	Once every plan year	Once every plan year
Contacts	Once every plan year	Once every plan year
Frames	Once every other plan year	Once every other plan year
Contact Lenses
Medically Necessary	$0 copay, paid in full	Up to $210 Reimbursement
Elective	Conventional:$0 copay; 15% off balance over $130 allowance; Disposable:$0 copay; 100% of balance over $130 allowance Fit and Follow-up - Standard Up to $40; Fit and Follow-up - Premium 10% off retail price	Up to $130 Reimbursement
Copay
Materials	$20 Copay	Up to $30 for single: Bifocal: Up to $50; Trifocal & Lenticular: Up to $70; (Reimbursement)
Examination	$10 Copay	Up to $40 Reimbursement
Covered Services
Frames	$0 copay; 20% off balance over $130 allowance	Up to $91 Reimbursement