Vision

Benefit	In-Network	Out-of-Network
	What You Pay
Routine Eye Exam Once per calendar year	$5 copay	Amount over $50
Routine Exam (PLUS Provider) Once per calendar year	$0 copay	Amount over $50
Eyeglass Lenses 1 Once per calendar year	$0	Amount over $50
Covered Lens & Frames Options 2
Standard Anti-Reflective	$45 copay	Amount over $5
Standard Polycarbonate (under age 19)	$0	Amount over $20
Standard Plastic Scratch Coating, UV Treatment, Tint (solid & gradient)	$0	Amount over $8
Eyeglass Frames Every other calendar year	Amount over $155 (20% discount off the balance over $155)	Amount over $70
Eyeglass Frames (PLUS Provider) Every other calendar year	Amount over $205 (20% discount off the balance over $205)	Amount over $70
Contact Lenses (in lieu of eyeglass lenses) Once per calendar year
Conventional/Disposable	Amount over $150 (15% discount off the balance over $150 for conventional)	Amount over $105
If Medically Necessary	$0	Amount over $210
LASIK/PRK Procedures (from the U.S. Laser Network)	15% discount off retail price or 5% discount off promotional price	N/A

The EyeMed PLUS Provider program’s benefits are built into Lennox’s standard EyeMed vision plan.

What is a PLUS Provider and what do they offer?

PLUS Providers within the EyeMed network offer enhanced benefits, such as:

• $0 annual routine eye exams, and
• An additional $50 towards their frames allowance – on top of your plan’s base coverage.

Where can you find an in-network PLUS provider?

By using EyeMed’s Provider Locator, you can search for nearby in-network providers and look for the PLUS icon beside their names to find a PLUS Provider near you.

A routine eye exam can help detect serious problems, such as diabetes, at an early stage. Type 1 and Type 2 diabetes could put you at risk of eye disease, including glaucoma, cataracts, and diabetic retinopathy.

You may qualify for a $0 copay or cost-reimbursed follow-up vision care services if you are eligible for EyeMed’s Diabetic Eye Care benefit. These services can be used once every 6 months.

DIABETIC EYE CARE COVERAGE
For Type 1 or Type 2 Diabetes with Diabetic Retinopathy	In-Network Member Cost	Out-of-Network Reimbursement Cost
Frequency: All Diabetic Care Services are covered once every 6 months
Medical Follow Up Eye Examination	$0 copay	Up to $77
Fundus Photography Examination	$0 copay	Up to $50
Extended Ophthalmoscopy (initial and subsequent)	$0 copay	Up to $15
Gonioscopy	$0 copay	Up to $15
Scanning Laser	$0 copay	Up to $33