Vision Benefits

---

The Episcopal Church Medical Trust: EyeMed Vision Care

Coverage Period: 01/01/2016—12/31/2016

Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage for: Vision

Benefit Description

Network

Out-of-Network

Eye Examinations

$0/visit

Lenses

You pay $10 for single, bifocal, or trifocal

Plan pays up to $30 for ophthalmologists and optometrists Plan pays up to: $32 – single vision $46 – bifocal $57 – trifocal

Frames

$130 allowance, 20% off balance over $130

Plan pays up to $47

Contact Lenses Conventional Disposable Standard Contact Lens Fit & Follow-Up Premium Contact Lens Fit & Follow-Up Lens Options Standard Progressive

$130 allowance, 15% off balance over $130 $130 allowance, then you pay balance over $130 You pay up to $55 10% off retail price

Benefit available once per calendar year.

You are eligible to receive lenses and frames or contact lenses once per calendar year.

Plan pays up to $100 Plan pays up to $100 N/A N/A

Plan pays up to $46 Plan pays up to $46

Standard Scratch Resistance Standard Polycarbonate

You pay up to $75 You pay $75, then 80% of charge less $120 allowance You pay up to $15 You pay $0

Standard Anti-Reflective Coating

You pay up to $45

UV Treatment

You pay up to $15

Tint (Solid and Gradient)

You pay up to $15

You are responsible for the cost of any lens options that you elect from out-of-network providers.

Other Add-Ons and Services

20% off retail price

Premium Progressive

Additional Information

When using network providers, the 20% discount for Other Add-Ons and Services includes but is not limited to polarized glasses and nonprescription sunglasses. You also receive 40% off additional eyewear purchases. For laser vision correction, you receive 15% off the retail price or 5% off the promotional price for LASIK or PRK procedures.

When you use EyeMed network providers, you will not need to submit a claim. Your EyeMed provider will submit claims on your behalf. You will pay the copayment at the time you receive services, as well as the costs for any non-covered expenses. For more information about EyeMed, and to see a list of EyeMed providers, visit www.eyemedvisioncare.com/ecmt , or call EyeMed at (866) 723-0513.