Jay School Corporation Vision Care Summary of Benefits
Summary of vision care benefits offered by Jay School Corporation, detailing in-network and out-of-network costs and coverage options.
Jay School Corporation SUMMARY OF BENEFITS VISION CARE IN-NETWORK OUT-OF-NETWORK SERVICES MEMBER COST MEMBER REIMBURSEMENT Save even more EXAM SERVICES Exam at PLUS Provider $0 copay Up to $45 with PLUS Providers Exam $0 copay Up to $45 Retinal Imaging Up to $39 Not covered CONTACT LENS FIT AND FOLLOW-UP Fit & Follow-up - Standard Up to $40; contact lens fit and two Not covered follow-up visits $50 Fit & Follow-up - Premium 10% off retail price Not covered Additional frame allowance from FRAME PLUS Providers* Frame at PLUS Provider $0 copay; 20% off balance Up to $105 over $200 allowance Frame $0 copay; 20% off balance Up to $105 *Compared to $150 frame over $150 allowance allowance at other EyeMed STANDARD PLASTIC LENSES in-network providers Single Vision $0 copay Up to $35 Bifocal $0 copay Up to $55 Trifocal $0 copay Up to $80 Lenticular $0 copay Up to $90 Find an eye doctor Progressive - Standard $55 copay Up to $50 Progressive - Premium Tier 1 - 4 $85 - 175 copay Up to $50 (Insight LENS OPTIONS Network) Anti Reflective Coating - Standard $45 copay Up to $23 • eyemed.com Anti Reflective Coating - Premium Tier 1 - 3 $57 - 85 copay Up to $23 • EyeMed Members App Photochromic - Non-Glass $75 Not covered • For LASIK, call Photochromic - Non-Glass < 19 years of age $0 copay Up to $38 1.800.988.4221 Polycarbonate - Standard $40 Not covered Polycarbonate - Standard < 19 years of age $0 copay Up to $20 Scratch Coating - Standard Plastic $0 copay Up to $8 Tint - Solid and Gradient $15 Not covered UV Treatment $15 Not covered All Other Lens Options 20% off retail price Not covered CONTACT LENSES Contacts - Conventional $0 copay; 15% off balance Up to $170 over $200 allowance Contacts - Disposable $0 copay; 100% of balance Up to $170 over $200 allowance Contacts - Medically Necessary $0 copay; paid-in-full Up to $300 OTHER Hearing Care from Amplifon Network Discounts on hearing aids; Not covered call 1.877.203.0675 Lasik or PRK from U.S. Laser Network 15% off retail or 5% off promo price; Not covered call 1.800.988.4221 FREQUENCY ALLOWED FREQUENCY – ALLOWED FREQUENCY – ADULTS KIDS Exam Once every plan year Once every plan year Frame Once every other plan year Once every other plan year Lenses Once every plan year Once every plan year Contacts Lenses Once every plan year Once every plan year (Plan allows member to receive either contacts and frame, or frame and lens services) QL-0000071368 EyeMed reserves the right to make changes to the products available on each tier. All providers are not required to carry all brands on all tiers. For current listing of brands by tier, call 866-939-3633. No benefits will be paid for services or materials connected with or charges arising from: medical or surgical treatment, services or supplies for the treatment of the eye, eyes or supporting structures; Refraction, when not provided as part of a Comprehensive Eye Examination; 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; orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; any Vision Examination or any corrective Vision Materials required by a Policyholder as a condition of employment; safety eyewear; solutions, cleaning products or frame cases; non-prescription sunglasses; plano (non-prescription) lenses; plano (non- prescription) contact lenses; two pair of glasses in lieu of bifocals; electronic vision devices; services rendered after the date an Insured Person ceases to be covered under the Policy, except when Vision Materials ordered before coverage ended are delivered, and the services rendered to the Insured Person are within 31 days from the date of such order; or lost or broken lenses, frames, glasses, or contact lenses that are replaced before the next Benefit Frequency when Vision Materials would next become available. Fees charged by a Provider for services other than a covered benefit and any local, state or Federal taxes must be paid in full by the Insured Person to the Provider. Such fees, taxes or materials are not covered under the Policy. Allowances provide no remaining balance for future use within the same Benefit Frequency. Some provisions, benefits, exclusions or limitations listed herein may vary by state.. Plan discounts cannot be combined with any other discounts or promotional offers. In certain states members may be required to pay the full retail rate and not the negotiated discount rate with certain participating providers. Please see online provider locator to determine which participating providers have agreed to the discounted rate.
