Eye Med Vision Care

Voluntary Vision Plan (covers lenses, frames and contacts)

Medical eligible employees are eligible to enroll in this benefit whether or not you are enrolled in the University medical plan. Also, this benefit will supplement the University’s CIGNA vision reimbursement plan or any other medical plan in which you may be enrolled.

Benefit Highlights

Vision Care Services

Member In-Network Coverage

(actual cost & discounts)

Out-of-Network Reimbursement

(allowance towards cost)

Frames (every 24 months)

· $150 allowance for frames

· 20% off of balance over $150

· 40% off additional frames purchased

· Up to $75

Contact Lenses (every 12 months)

Conventional

Disposable*

Medically Necessary**

· $150 allowance

· 15% off balance over $150

· 15% off additional pairs

· $150 allowance

· Paid in full

· Up to $120

· Up to $200

Lenses (every 12 months)

Single Vision

Bifocal

Trifocal

Standard Progressive

Premium Progressive**

· $20 copay

· $85 copay

· $85 copay then pay 80% charges less the $120 allowance

· Up to $11

· Up to $25

· Up to $49

· Up to $25

Lens Options (every 12 months)

(Cost added to the base price of the lens)

Tint

UV Treatment

Standard Scratch Resistant Coating

Standard Polycarbonate

Anti-Reflective

Polarized

Other Add-Ons & Services

· $15

· $0

· $40

· $45

· 20% off retail

· N/A

· Up to $11

· N/A

Lasik and PRK Vision Correction Procedures

· 15% off retail price OR 5% off promotional pricing

· N/A

Value Added Feature

Eye Care Supplies

· 20% off retail price for eye care supplies like cleaning clothes and solutions purchased at network providers

* In order to get full allowance, you must order a full year of lenses at time of purchase.

**Examples of circumstances where medically necessary contact lenses are needed.

- Keratoconus where the member is not correctable to 20/30 in either or both eyes using standard spectacle lenses.

- High Ametropia exceeding –12D or +9D in spherical equivalent

- Anisometropia of 3 D or more

- Members whose vision can be corrected by two (2) lines of improvement on the visual acuity chart when compared to best corrected spectacle lenses.

Member Out-of-Pocket Examples

Using an in-network provider

Example 1	Member selects pair of eyeglasses with standard progressive lenses & plastic scratch coating
		Estimated U&C Cost	Member Cost	Member $ Savings	Member % Savings
	Frame ($150 allowance)	$150	$0	$150	100%
	Standard Progressive Lenses	$200	$85	$115	58%
	Standard Plastic Scratch Coating	$25	$0	$25	100%

	Total	$375	$85	$290	77%

Example 2	Member selects pair of eyeglasses with single vision, polycarbonate lenses
		Estimated U&C Cost	Member Cost	Member $ Savings	Member % Savings
	Frame ($150 allowance plus 20% off balance over $150)	$200	$40	$160	80%
	Single Vision Lenses	$120	$20	$100	83%
	Standard Polycarbonate	$90	$40	$50	56%

	Total	$410	$100	$310	76%

Benefits are not provided for services or materials arising from: Orthopedic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; Medical and/or surgical treatment of the eye, eyes or supporting structures; Any eye or Vision Examination, or any corrective eyewear required by a Policyholder as a condition of employment; safety eyewear; 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; Plano (non-prescription) lenses and/or contact lenses; Prescription and non-prescription sunglasses; Two pair of glasses in lieu of bifocals; Services or materials provided by any other group benefit plan providing vision care; Certain brand name Vision Materials in which the manufacturer imposes a no-discount policy; or 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. Lost or broken lenses, frames, glasses, or contact lenses will not be replaced except in the next Benefit Frequency when Vision Materials would next become available. Benefits may not be combined with any discount or promotional offering.

Benefit summaries are provided for the convenience of Wesleyan employees. Employees are directed to read the relevant benefit plan documents. In the event of a conflict between the terms of any summary and the terms of actual plan document, the terms of plan documents will control. Except where prohibited by collective bargaining or other agreement, Wesleyan reserves the right to alter, modify or suspend any benefit at any time. While Wesleyan selects its benefit providers after thoughtful review, it disclaims responsibility for the ultimate performance of such providers.

Who is Eligible?

• Spouse

• Dependent Children up to age 26 (regardless if they are a full time student)

• An unmarried same or opposite-sex, long-term domestic partner and the partner dependent child(ren), if they satisfy eligibility requirements.

Finding In-Network Providers

• To see a list of participating providers near you, go to www.enrollwitheyemed.com and choose SELECT from the provider locator dropdown box.

• Call 1-866-299-1358

• Participating “big box” providers are LensCrafters, Pearle Vision, Sears Optical, Target Optical and JCPenny.

If you have questions concerning this benefit, please send an e-mail to benefits@wesleyan.edu.