2024 Employee Benefit Guide - Salaried - Yeled 11.3.23

VISION CARE PLAN - INSIGHT NETWORK

OUT-OF-NETWORK REIMBURSEMENT

BENEFIT

IN-NETWORK

FREQUENCY

Eye Examination

Up to $40

Every 12 months

$20 Copay

Retinal Imaging

Up to $39 reimbursement

Not covered

Every 12 months

Lenses Single Vision Lined Bifocal Lined Trifocal Lenticular

$25 Copay $25 Copay $25 Copay $25 Copay $90 Copay

Up to $30 Up to $50 Up to $70 Up to $70 Up to $50 Up to $50 Up to $50 Up to $50 Up to $50

Standard Progressive Premium Progressive

Every 12 months

Tier 1 Tier 2 Tier 3 Tier 4

$110 Copay $120 Copay $135 Copay $90 Copay 80% of charge less $120 allowance

Contact Lenses Medically Necessary

$0 Copay Paid In Full

Up to $300

•

Conventional

$0 Copay $150 allowance, 15% off balance over $150 $0 Copay $150 allowance 100% of balance over $150

Up to $150

•

• •

Every 12 months

Disposable

Up to $150

• •

Contact Lens Fit and Follow-up Standard Contact Lens Premium Contact Lens

Up to $40 reimbursement 10% off retail

Not Covered Not Covered

Frames

$0 copay $150 allowance 20% off balance over $150

Up to $105

Every 24 months

Dependent Age Limit: To age 26; benefits terminate at the end of the month in which the dependent turns 26

PRE-TAX MONTHLY CONTRIBUTIONS

Employee

$6.61

Family

$16.87

Contributions are deducted on a monthly basis on the second paycheck of every month

For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.