HomeMy WebLinkAboutCONTRACT BETWEEN AUGUSTA, GEORGIA AND EYEMED_LOW OPTION e Augusta,GA Version 7
E Voluntary Plan A,Fixed Fee
VoWrrory
Option t Low Plan
EyeMed Vision Care in conjunction with Combined insurance Company of America
Vision'Care Services Member Cost In-Network Out-of-Network Reimbursement*
Exam with Dilation as Necessary $10 Copay 525
Contact Lens Fit and Follow-Up:
(Contact lens fit and two follow-up visits are available once a campret nsive eye exam has been compered.)
Standard Contact Lens Fit and Follow-Up: SO Copay,Paid-in-full fit and two follow-up visits $40
Premium Contact Lens Fit and Follow-Up: $0 Copay,10%off retail price,then apply$40 allowance
$40
Frames:
SO Copay;$100 Allowance,20%off balance over$100 $50
Any available frame at provider location
Standard Plastic Lenses
Single Vision S5 Copay $20
Bifocal $5 Copay $35
Trifocal $5 Copay $60
Standard Progressive Lens $70 Copay $35
Premium Progressive Lens $70 Copay,80%of Charge less$120 Allowance $35
Lens Options:
W Treatment $15 N/A
Tint(Solid and Gradient) $15 N/A
Standard Plastic Scratch Coating SO Copay $11
Standard Polycarbonate-Adults $40 N/A
Standard Polycarbonate-Kids under 19 $40 N/A
Standard Anti-Reflective Coating $45 N/A
Polarized 20%off Retail Price N/A
Other Add-Ons 20%off Retail Price
N/A
Contact Lenses
(Contact lens allowance includes materials only)
Conventional $5 Copay;$100 allowance,15%off balance over$100 $65
Disposable 55 Coney;$100 allowance,plus balance over 5100 $65
Medically Necessary $0 Copay,Paid-in-Full $200
Laser Vision Correction
Lasik or PRI(from U.S.Laser Network 15%off Retail Price or 5%off promotional price N/A
Amplifan Hearing Health Care Hearing Health Care from Amplifon Hearing Health Care Network
Members receive a 40%discount off hearing exams and a low price guarantee on discounted N/A
hearing aids.
Additional Pairs Benefit also receive a 40%discount off complete pair eyeglass purchases and a 15%discount N/A
off conventional contact lenses once the funded benefit has been used.
Frequency:
Examination Once every 12 months
Lenses or Contact Lenses Once every 12 months
Frame
Once every 12 months
Monthly Rate
Subscriber $6.14
Subscriber*1 $12.30
Subscriber*Family $16.90
All plans are based on a 48-month contract term and 48-month rate guarantee.
Premium is subject to adjustment even during a rate guarantee period in the evert of any of the following events:changes in benefits,employee contributions,the number of eligble employees,or the imposition
of any new taxes,fees or assessments by Federal or State regulatory agencies
'Member Reimbursement Out-of-Network will be the lesser of the listed amount or the member's actual cost from the out-of-network provider.M certain states members maybe required to pay the full retail rate and not
the negotiated discount rate with certain participating providers.Please see EyeMed's onbne provider locator to determine which participating providers have agreed to the discounted rate
Additional Discounts:
Memner recedes ane.atscount on items not coverts oy tre plan at netvrorK I-roomers.viscount aces ixjl,,Appy ustuedyq tyovroers professional services,or contact tenses.rum aiscamts canna ne
combined with any other discounts or promotional offers.Services or materials provided by any othvlreupbenefit plan'providmg dtt6MEMr•wty not-a ,,n.
, .,.„._.T->....
Members also receive 15%off retail price or 5%off promotional price for Lasik or PRK from the US Lash Network,owned and operated by LCA Vision.
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.eyemedvisi` are.com.
The contact lens benefit allowance is not applicable to this service. r ���
Benefit Allowances provide no remaining balance for future use within the same Benefit Frequency. 4� �
Certain brand name Vision Materials in which the manufacMer i a no-discount practice. I). �'1'VILA(H,a .,1'
Rates are valid only when the quoted plan is the sole stand-alone vision plan offered by the group - • °S9�,p •8
Rates are valid for groups domiciled M the State of GA } +4 s� mss..*�wnape YYY???
Fees quoted will be ootid until the 1/1/2018 plan implementation date.Date quoted:5/16/2017. 1 Mr sept ere ®b " '�
Rates assume Employer contribution of 20%or less for employees and dependents 0- p • , •• ,,
Insured Plans are underwritten by Combined Insurance Company of erica,5050 Broadway,Chicago&IL 60640, , opN Vor(q'« ...e17-1 ® i�# 4
Plan Exclusions: �g 3- 3
1)Orthoptic or vision trainsrr, F ,
rtirop training,subrormal vision aids and any associated supplemental testing;Aniselkodc )Aicditll ant/ �
3)Any eye or Vision Examination,or any corrective eyewear required a Pa /p,. �y eye,Qves ors,0portnf�fnxtures;
by k34roluter as a uxKditioh of • '@x � ..t..„.),;), qP- T RF-fr
4)Services provided as a result of any Workers'Compensation taw,or similar legislation,or required by any•• - % nal,stale or su l.isionstAereof;
5)Plano(non-prescription)lenses and/or contact lenses;6)Nonprescription sunglasses;7)Two pair of glasses in fS 10 +J
8)Services rendered after the date an inured Person ceases to be covered under the Policy,exceptwhen Vision f before ended arm felfve l,� r
and the services rendered to the Insured Person are within 31 days from the date of such order,9)5evices or ma prov�ay older a p ...n. _vision coos;
10)Lost or broken lenses,frames,glasses,or contact - .. to..,.-,except in the .Benefit F:. - 4.; Vision • .,.won.•' -ava e. .'?
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