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Summary of Benefits for: Vision 6 EyeMed Select Network Exam with Dilation as Necessary Contact Lens Options Standard fit & follow-up Premium fit & follow-up Frames Any frame at provider location Standard Plastic Lenses Single Vision Bifocal Trifocal Standard progressive Lens Options UV Coating Tint (Solid and Gradient) Standard Scratch-Resistance Standard Polycarbonate Standard Anti-Reflective Other Add-ons and Services Contact Lenses Conventional Disposables Medically Necessary Laser Correction (US Laser Network) Lasik or PRK Frequency Examination Frames Lenses or Contact Lenses Once every 12 months Once every 12 months Once every 24 months Once every 24 months Once every 12 months Once every 12 months 20% off retail price Not covered Declining Balance Allowance Up to $100 $0 copay: $115 allowance; member responsible for balance over $115 Up to $100 $0 copay: paid in full Up to $200 15% off retail price -or- 5% off promotional price Not covered $0 copay: $115 allowance; 15% off balance over $115 Not covered $45 $15 Not covered $15 Not covered $40 Not covered $10 Up to $55 $15 Not covered $75 Up to $40 $10 Up to $25 $10 Up to $40 10% off retail price Not covered Up to $50 $0 copay, $100 allowance; 20% off balance over $100 Up to $40 Not covered City of Burley In-Network (Member Cost) Out-of-Network (Reimbursement) $10 Up to $35 10/18/2019 12:40 PM ---PAGE BREAK--- Dental Notes for: Vision Plan Notes ● ● ● ● ● ● ● ● ● ● Vision Plan Exclusions (10) (11) (12) (13) This summary of benefits is current as of 10/18/2019. To verify up to date benefits, please contact Dental Select Customer Care. Sub-normal vision aids or non-prescription lenses. Photorefractive Keratectomy (PRK) surgery or Laser-assisted in Situ Keratomileusis (LASIK) surgery. The EyeMed Network offers access to thousands of independent vision care providers and top optical retailers nationwide, including: Medical or surgical treatment of the eyes. Charges in excess of the Usual and Customary charge for the Service or Any eye examination, or any corrective eyewear, required by an employer as a condition of employment. Charges incurred after: the Policy ends; or the Insured’s coverage under the Policy ends, except as stated in the Policy. Services provided as a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof. Experimental or non-conventional treatment or devices. Lost or broken Materials, except when replaced at normal intervals when Services are available. Allowances Allowances are one-time use benefits; no remaining balance except for contact lens materials, when applicable. Lost or broken materials are not covered. Discounts on products and Services are not insured benefits and not underwritten by ACE American Insurance Company. Orthoptic or vision training and any associated supplemental testing. Services rendered or Materials purchased outside the U.S. or Canada, unless: the Insured resides in the U.S. or Canada; and the charges are incurred while on a business or pleasure trip. Plano lenses. Two pair of glasses, in lieu of bifocals or trifocals. Tier 2 Lenses: The Member's copay for all tier 2 lenses is calculated by adding the copay of Standard Progressive Lenses plus an additional Lasik & PRK Since Lasik or PRK vision correction is an elective procedure, performed by specially trained providers, this discount may not always be available from a provider in your immediate location. For a location near you and the discount authorization, please call 1-877-5LASER6. Tier 3 Lenses: The Member's copay for all tier 3 lenses is calculated by adding the copay of Standard Progressive Lenses plus an additional Tier 4 Lenses: The Member's copay for all tier 4 lenses is equal to the copay of Standard Progressive Lenses, with an allowance of $120 and a 20% discount after allowance. Dependent Eligibility Eligible dependents are covered up to age 26. Premium Progressive Lenses (Insight Network only) This discount may not be combined with any other discounts or promotional offers and does not apply to EyeMed Provider's Premium Progressive Lenses are classified into "tiers" based on the brand and other factors. A Member's Copay varies based on the tier of the lens. A list of lenses by tier can be found at Retail prices may vary by location. Discounts do not apply to benefits provided by other group benefit When enrolled on the vision plans, Members receive a 40% discount off complete eyeglass purchases and a 15% discount off conventional contact lenses at unlimited frequency after the initial benefit has been used. After initial purchase, replacement contact lenses may be obtained via the internet at substantial savings and mailed directly to the member. Details are available at www.eyemedvisioncare.com. The contact lens benefit allowance is not applicable to this service. Tier 1 Lenses (Vis6, Vis8, Vis12): The Member's copay for all tier 1 lenses is calculated by adding the copay of Standard Progressive Lenses plus an additional $20. Tier 1 Lenses (Vis21): The Member's copay for all tier 1 lenses is equal to the copay of Standard Progressive Lenses. All Premium Progressive Lenses are subject to an Annual Allowance of $120. Members will receive a 20% discount on items not covered by the plan when using contracted providers. City of Burley Premium Progressive Lenses (Select Network only) Discounts 10/18/2019 12:40 PM