HomeMy WebLinkAboutCONTRACT BETWEEN AUGUSTA, GEORGIA AND EYE MED_ HIGH OPTION Augusta,GA versmm 7
EyeMed Select Plan A,Fined Fee
Voluntary
Option 1-Nigh OPlwn
EyeMed Vision Core in conjunction with Combined insurance Company of America
vision Care Services Member Cost In Network Out-of-Network Reim)PUrsemegt' r'
Exam with Dilation as Necessary - 510 Copay 52$
Contact Lens Fit and Follow-Up:
(Contact tees fit and two follow-up visits are available once a mmprehensive eye exam has been completed.I
Standard Contact Lem Fit and Follow-Up: SO Casey,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:
$0 topay;$200 Allowance,20%off balance over 5200 5100
Any available frame at provider location
Standard Plastic Lenses
Single Vision 55 Capay $20
Bifocal $5 Copay 535
Trifocal $5 Copay $60
Lenticular $5 Copay $60
Standard Progressive Lens $70 Copay $35
Premium Progressive Lens $70 Copay,80%of Charge less$120 Allowance $35
Lens Options:
UV Treatment $15 N/A
Tint iSolid and Gradient) 515 N/A
Standard Plastic Scratch Coating $0 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
Photocromatic/Transitions Plastic $25 Copay $45
Other Add-Ons 20%off Retail Price N/A
Contact Lenses
(Contact les allowance Includes motet**only)
Conventional 55 Copay;$200 allowance,15%off balance over$200 5140
Disposable 55 Copay,$200 allowance,pita balance over 5200 5140
Medically Necessary $0 Copay,Paid-In-Full $200
Laser Vision Correction
Lasik or PRK from U.S.Laser meteoric 15%off Retail Price or 5%off promotional price N/A
Hearing Health Care from Amplffon Nearing Health Care Network
Anplifon tearing Health Care Members receive a 40%discount off hearing exams and a low price guarantee on discounted N/A
hearing aids.
AdditIo all Members also receive a 40%discount off complete pale eyeglass purchases and a 15%discount N/A
off conventional contact tenses 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 59.10
Subscriber•1 $18.23
Subscriber•Family 525.05
All plans are based on a 48-month contract term and 48-month rate guarantee.
Premium k subject to adjustment even during a rate guarantee period In the event of any of the following events:changes in benefits,employee contriledions,the number of eligible employees,or the Imposition
of any new taxes,fees or assessments by Federal or State regulatory agencies
•Member Reimbursement.Out-of-Network will be tie lesser of the listed amount or the member's actual cost from Me out-of-network provider.N certain states members may be required to pay the full retail rate and not
the negotiated discount rate with chain participating providers.Please see EyeMed•s online provider locator to determine which participating provides have agreed to the discounted rate
Additional Dbcoures:
Member receives a 20%discounton Items ret covered by the Wan at network Providers.Discount does rip",to EyeMed Providers professional service{,er antsu-Ieeaaa,Ayandlstpmo cannot tie
combined with any other discounts or promotional offers.Services or materials provided by any other dlN/�Ifireitj`v"`llon'rare may not be covered. •'•.
Northers also receive 15%off retail price or 5%of promotional peke for Laslk or PRI from the US Laseowned and operated by ICA Vision.
After Initial purchase,replacement contact lenses may be obtained via the anernet at substantial ailed directly t the member.Details are available at www.eyemedvislonare.com.
The contact lens benefit allowance Is not applicable to this service. ��r<sVrltRy�
Benefit Allowances provide oe remaining balance f«future use within the same Benefit Frequency. 4 CIA
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Certain brand name Vision Materials In which the manufacturer Imposes a no-discount practice. nM- A i+%F+p8Rates are valid only when the quoted plan k the sole standalone vision Wan offered by the gro pRates we valid for gro ps domiciled in the State of GA. ffP 't1 �"yysiFees quoted will be valid until the 1/1/2018 plan lmplemenatkn date.Date quoted:5/16/2017. 4s''Rare asnme Employer uxxeributton o 20%«less f«employees and dependenKIn ,s^ o •InsuredPorroareuidewrlttenbyCmrbinedInsuranceCompanyofMnenice,5050Broadway,Chiago exce YIbk ,3ri, 4Fi'r- 'k OS ii von
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'Plan Exclusions: sy •fit t� . gl e'
1)Orthoptic or vision baiting,subnormal vision aids and any associated supplemental testing;Aelseikonl :lenses 2/ • I art/or "-i %d"F eyes`jr stnrc uees;
3)Any eye or Vision Examination,or any corrective eyewear required by a Policyholder as a condition of if iety mpssear Y.t f'"s`•Lr' 0 s
4)Services provided as■result of any workers'Compensation law,or similar legislation,or required bya�Y gore ly`en�or prs t�*daeI0jate a bd�rsvpm the
51 Plano(non-prescrdpfio i lenses and/or contact lenses;6)Non-prescription s nglasses;7)Two pair of flksses in Ise. , . :•
a)Services rendered after the date an Insured Person ceases to be covered aider the Policy,except when Vision Mates • •- • ' • coversg ed are dei r, • ®
andinsured
the services een:Weed to the insured Person are within 31 days iron.the date of such order,9)Serviceso materials ..);.„-.1:
h'� group bene( . •p,��^^_,rare; yl
10)Lost or broken lenses,frames,glasses,or•.. .. t
..be replaced except in o next Dem Fag j N. availab4 " • /♦4�
II Augusta,GA has benefit ,,gj � /war ,13.0,0 4. ....if ,v�,V
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Signature ��\ Date �1.4
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