Advocate Health Care
Benefits
Vision

 
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Primary Benefits

The primary benefits provided by the Advocate Vision Plan are summarized below.

Vision Care Services Your cost
(when you use
an EyeMed network
provider):		 Your reimbursement
(when you DON'T use
an EyeMed network
provider):
Exam (with dilation, as necessary)—once every 12 months $10 copayment Up to $35
Frames—once every 12 months After plan pays up to
$100, you pay 80% of
any remaining balance		 Up to $45
Standard Plastic Lenses (in place of contact lenses)—once every 12 months
·  Single Vision
·  Bifocal
·  Trifocal
·  Lenticular

$10 copayment
$10 copayment
$10 copayment
$10 copayment

Up to $25
Up to $40
Up to $55
Up to $55
Lens Options—paid by you and added to base price of lens
·  UV Coating
·  Tint - solid and gradient
·  Standard Scratch Resistance
·  Standard Progressive - add-on to bifocal
·  Standard Anti-Reflective
·  Other Add-ons and Services

$12
$12
$15
$35
$45
$45

na
na
na
na
na
na
Contact Lenses (in place of standard plastic lenses)—once every 12 months; includes initial fit, follow-up and materials
·  Conventional


·  Disposables


·  Medically Necessary


After plan pays up to
$115, you pay 85% of
any remaining balance
After plan pays up to
$115, you pay 100% of
any remaining balance
After plan pays up to
$250, you pay 100% of
any remaining balance


Up to $100


Up to $100


Up to $200
LASIK and PRK Vision Correction Procedures 85% of retail price OR 95% of promotional pricing na

Additional purchases and out-of-pocket discounts
If you elect this coverage, you will receive a 20% discount on remaining balances at participating providers beyond plan coverage. This discount will not apply to the professional service fees of EyeMed providers or the cost of disposable contact lenses. Retail prices may vary by location. Benefits may not be combined with any discount, promotional offering or other group benefit plans. Allowances are one-time use benefits; no remaining balance. Lost or broken materials are not covered.

Limitations/exclusions
The Advocate Vision Plan will not pay benefits for the following services and materials:

Orthoptic or vision training, subnormal vision aids and any associated supplemental testing.
Medical and/or surgical treatment of the eye or supporting structures.
Corrective eyewear required by an employer as a condition of employment, and safety eyewear unless specifically covered under the plan.
Services provided as a result of any Workers’ Compensation law.
Plano non-prescription lenses and non-prescription sunglasses (except for 20% discount).
Two pairs of glasses in lieu of bi-focals.