Benefits-At-A-Glance 2015 Plan Year This report shows 2015 TriNet Passport benefit year plan options available in: CT, NJ, NY When your business' success depends on your smart decisions, having accurate, easy-to-read information is critical. After all, your decisions can only be as smart as the data behind them. TriNet is here to help you make the right decisions about worksite employee benefits with experienced guidance and best-in-class tools, including this Benefits-At-A-Glance (BAAG) plan comparison summary. And that s important, because making the right decisions about benefits can give you a competitive advantage, helping you recruit, retain, and engage the talent that powers your company. TriNet Passport benefit offerings give you the benefit choices you need to engage a highperforming workforce as well as the information you need to make smart decisions about those benefits. Disclaimer: This proprietary communication has been prepared for educational and informational purposes only. The content does not provide legal or tax advice, or legal opinions on any specific matters. Transmission of this information is not intended to create, and receipt does not constitute, an attorney-client relationship between TriNet and you. TriNet is not an insurance company, but rather is the single-employer sponsor of all its health and welfare plans. Nothing contained herein constitutes an offer to sell, buy, or procure insurance. TriNet is the single-employer sponsor of all its benefit plans. TriNet makes these plans available to qualifying worksite employees ("WSEs"), with whom TriNet has established an employment relationship, and who perform services for customers of TriNet in a Professional Employer Organization ("PEO") or service model. Under this model, TriNet incurs all expenses associated with its plan sponsorship and maintenance, and TriNet bills the customer for its services. The customer has no other financial obligation to TriNet, its other customers, or any of its insurance carriers for benefit plans sponsorship or provision. TriNet carriers have no recourse against TriNet customers. Other than compliance with TriNet contract terms, customers have no legal responsibilities to TriNet or the WSEs or any other TriNet customer for plan sponsorship or compliance. Federal and state laws may impose obligations on our customers independent of TriNet role as the plan sponsor. Because TriNet does not provide tax or legal advice, customers should address the resolutions of these obligations with their advisors. Any references to "your benefit programs or plans" are not legal terms or terms of art, and should not be confused with legal plan sponsorship, participation, or fiduciary compliance, These terms and others, such as "your employees" or "your selections, plan, or investments," are used solely as lay terms of convenience so that you understand we are referring only to the decisions made and TriNet plans available in a specific worksite or to a specific group of WSEs. Insurance coverage exclusions and limitations apply. In the event there is a conflict between any of the information contained in any benefits guidance materials provided by TriNet (including but not limited to information contained in any TriNet website, TriNet Benefits Enrollment Confirmation, any written or electronic pamphlets, letters, emails, text messages, and statements made by TriNet worksite employees) and the TriNet Plan document, the Plan document shall control. Also, if there is a conflict between an official certificate provided by TriNet insurance carrier(s) (the "Carrier Certificate") and either the TriNet Plan document, any TriNet Summary Plan Description, statements made by a TriNet employee, or any other benefits guidance materials provided by TriNet (including but not limited to those described above), the Carrier Certificate shall control. Please note: Information contained in this summary may be updated at any time based on additional clarifications due to recent health care reform legislation and state mandates. 2012-2014 TriNet. All rights reserved. All trademarks, trade names, service marks and logos referenced herein belong to their respective companies.
Medical Plans Plan Basics Aetna NY Tri-State EPO 20 Aetna NY Tri-State EPO 25 Aetna NY Tri-State EPO 30 Aetna HDHP 2000 NY Tri- State Regional Plan Names Aetna NY Tri-State EPO 20 Aetna NY Tri-State EPO 25 Aetna NY Tri-State EPO 30 Aetna HDHP 2000 NY Tri-State Plan Locations CT, NJ, NY CT, NJ, NY CT, NJ, NY CT, NJ, NY Carrier Network Aetna Open Access Elect Choice Aetna Open Access Elect Choice Aetna Open Access Elect Choice Aetna Managed Choice POS Open Access Plan Features Calendar-Year Deductible (Deductible applies where specifically stated) None $1,000/person; $2,500/family None $2,000/person*; $4,000/family * (does not apply if the employee and any family members are enrolled in the plan) $4,000/person*; $8,000/family Deductible Carryover (Any covered expenses incurred in the last 3 months of a Calendar Year that applytoward that year's network/out-of-network Calendar Year will also count toward the following year'snetwork/out-of-network Calendar Year.) NA Yes NA No Calendar-Year Out-of-Pocket Expense Maximum (Includes, coinsurance and medical/rx copays unless otherwise stated) * (does not apply if the employee and any family members are enrolled in the plan) $3,000/person; $7,500/family $4,000/person; $10,000/family $3,500/person; $8,750/family $4,500/person*; $9,000/family $8,000/person*; $16,000/family Lifetime Benefits Maximum Unlimited Unlimited Unlimited Unlimited Routine Health Maintenance Preventive Care Well-woman Well-baby Well-man (Includes annual Pap smear, routine mammogram, and annual prostate exam) Vision Testing Not covered Not covered Subject to routine physical exam cost sharing Not Covered Hearing Testing 8/28/2014 2
Aetna NY Tri-State EPO 20 Aetna NY Tri-State EPO 25 Aetna NY Tri-State EPO 30 Aetna HDHP 2000 NY Tri- State Physician Hospital Services Physician Office Visit $20/visit $40/visit $25/visit $40/visit $30/visit $50/visit 90% covered after Surgery Outpatient 80% after 90% covered after Hospital Inpatient Room and Board Surgery Anesthesia Drugs/Supplies after $200/day for first 3 days 80% after after $750/admission 90% covered after Emergency Room (Copay waived if admitted) $200/visit $200/visit $200/visit 90% covered after 90% covered after Urgent Care $75/visit $75/visit $75/visit 90% covered after Pregnancy Maternity Care Prenatal Care and Inpatient Visits: Inpatient: after $200/day for first 3 days Visits: Inpatient: 80% covered after Visits: Inpatient: after $750/admission Visits: Inpatient: 90% covered after Prescription Drugs Retail Pharmacy In-Network (30-day supply if not specified) Dollar amounts listed are generic/formulary brand/ non-formulary brand $10/$30/$50 Prescription drug plan year : $100 individual/$300 family $10/$30/$50 Prescription drug plan year : $100 individual/$300 family $10/$30/$50 Prescription drug plan year : $100 individual/$300 family $10/$30/$50 after Must be met before any drug benefits are paid Must be met before any drug benefits are paid Must be met before any drug benefits are paid Mail-Order Program In- Network (90-day supply if not specified; out-of-network not covered) Dollar amounts listed are generic/formulary brand/ non-formulary brand $20/$60/$100 Prescription drug plan year : $100 individual/$300 family Must be met before any drug benefits are paid. Mandatory mail order for all maintenance drugs. Refer to COC for further details. $20/$60/$100 Prescription drug plan year : $100 individual/$300 family Must be met before any drug benefits are paid. Mandatory mail order for all maintenance drugs. Refer to COC for further details. $20/$60/$100 Prescription drug plan year : $100 individual/$300 family Must be met before any drug benefits are paid. Mandatory mail order for all maintenance drugs. Refer to COC for further details. $20/$60/$100 after Specialty Pharmacy (Includes many specialty drugs. Call your carrier for more information.) Refer to your COC or contact Aetna for further details Must use Aetna s specialty retail mail order after 1st purchase from retail pharmacy Refer to your COC or contact Aetna for further details Must use Aetna s specialty retail mail order after 1st purchase from retail pharmacy Refer to your COC or contact Aetna for further details Must use Aetna s specialty retail mail order after 1st purchase from retail pharmacy. Refer to your COC or contact Aetna for further details 8/28/2014 3
Aetna Out-of-Area HDHP Aetna Indemnity Aetna POS 15 NY Tri-State Aetna POS 20 NY Tri-State Plan Basics Regional Plan Names Aetna HDHP 2000 Aetna Indemnity Aetna POS 15 NY Tri-State Aetna POS 20 NY Tri-State Plan Locations Nationwide - Limited counties, except MA Nationwide - Limited counties, except MA CT, NJ, NY CT, NJ, NY Carrier Network Aetna Open Choice PPO Not applicable Aetna Managed Choice POS Open Access Aetna Managed Choice POS Open Access Plan Features Calendar-Year Deductible (Deductible applies where specifically stated) * (does not apply if the employee and any family members are enrolled in the plan) $2,000/person*; $4,000/family $4,000/person*; $8,000/family $1,000/person; $3,000/family None $500/person; $1,500/family None $750/person; $1,875/family Deductible Carryover (Any covered expenses incurred in the last 3 months of a Calendar Year that applytoward that year's network/out-of-network Calendar Year will also count toward the following year'snetwork/out-of-network Calendar Year.) No Yes Yes Yes Calendar-Year Out-of-Pocket Expense Maximum (Includes, coinsurance and medical/rx copays unless otherwise stated) * (does not apply if the employee and any family members are enrolled in the plan) $4,500/person*; $9,000/family $8,000/person*; $16,000/family $4,000/person; $12,000/family $2,500/person; $6,250/family $3,500/person; $8,750/family $3,000/person; $7,500/family $3,750/person; $9,375/family Lifetime Benefits Maximum Unlimited Unlimited Unlimited Unlimited Routine Health Maintenance Preventive Care Well-woman Well-baby Well-man (Includes annual Pap smear, routine mammogram, and annual prostate exam) 80% covered after 80% covered after Vision Testing Not Covered Not Covered for routine screenings (1 routine exam every 12 months) Not Covered 80% covered after Hearing Testing for routine screenings 80% covered after 80% covered after 8/28/2014 4
Aetna Out-of-Area HDHP Aetna Indemnity Aetna POS 15 NY Tri-State Aetna POS 20 NY Tri-State Physician Hospital Services Physician Office Visit 90% covered after 80% covered after $15/visit $20/visit 80% covered after $20/visit $30/visit 80% covered after Surgery Outpatient 90% covered after 80% covered after $75/visit (facility only) 80% covered after 80% covered after Hospital Inpatient Room and Board Surgery Anesthesia Drugs/Supplies 90% covered after 80% covered after $250/visit 80% covered after after $350/confinement 80% covered after Emergency Room (Copay waived if admitted) 90% covered after 80% covered after $100/visit $100/visit 90% covered after $100/visit $100/visit Urgent Care 90% covered after 80% covered after $75/visit $75/visit 80% covered after 80% covered after Pregnancy Maternity Care Prenatal Care and Inpatient Visits: Inpatient: 90% covered after Inpatient: 80% covered after Office visits: Inpatient: $250/visit Inpatient: $350 copay/confinement 80% covered after 80% covered after Prescription Drugs Retail Pharmacy In-Network (30-day supply if not specified) Dollar amounts listed are generic/formulary brand/ non-formulary brand Mail-Order Program In- Network (90-day supply if not specified; out-of-network not covered) Dollar amounts listed are generic/formulary brand/ non-formulary brand $10/$35/$60 after $10/$35/$60 $10/$30/$50 $10/$30/$50 $20/$70/$120 after $20/$70/$120 $20/$60/$100 $20/$60/$100 Specialty Pharmacy (Includes many specialty drugs. Call your carrier for more information.) 25% of prescription cost, up to $250/prescription, with prior authorization, after 25% of prescription cost, up to $250/prescription, with prior authorization Refer to your COC or contact Aetna for further details Refer to COC or contact Aetna for further details 8/28/2014 5
Aetna POS 30 NY Tri-State Aetna PPO 750 NY Tri-State Aetna PPO 1000 NY Tri-State Aetna Out-of-Area PPO Plan Basics Regional Plan Names Aetna POS 30 NY Tri-State Aetna PPO 750 NY Tri-State Aetna PPO 1000 NY Tri-State Aetna PPO 1000 Plan Locations CT, NJ, NY CT, NJ, NY CT, NJ, NY Nationwide - Limited counties, except MA Carrier Network Aetna Managed Choice POS Open Access Aetna Managed Choice POS Open Access Aetna Managed Choice POS Open Access Aetna Open Choice PPO Plan Features Calendar-Year Deductible (Deductible applies where specifically stated) * (does not apply if the employee and any family members are enrolled in the plan) None $2,000/person; $5,000/family $750/person; $1,875/family $1,000/person; $2,500/family $1,000/person; $2,500/family $1,500/person; $3,750/family $1,000/person; $3,000/family $3,000/person; $9,000/family Deductible Carryover (Any covered expenses incurred in the last 3 months of a Calendar Year that applytoward that year's network/out-of-network Calendar Year will also count toward the following year'snetwork/out-of-network Calendar Year.) Yes Yes Yes Yes Calendar-Year Out-of-Pocket Expense Maximum (Includes, coinsurance and medical/rx copays unless otherwise stated) * (does not apply if the employee and any family members are enrolled in the plan) $4,000/person; $10,000/family $5,000/person; $12,500/family $4,000/person; $10,000/family $6,000/person; $15,000/family $6,000/person; $12,000/family $8,000/person; $20,000/family $4,000/person; $12,000/family $8,000/person; $24,000/family Lifetime Benefits Maximum Unlimited Unlimited Unlimited Unlimited Routine Health Maintenance Preventive Care Well-woman Well-baby Well-man (Includes annual Pap smear, routine mammogram, and annual prostate exam) 60% covered after Vision Testing Not Covered Not Covered Not Covered Not Covered Hearing Testing 60% covered after 8/28/2014 6
Aetna POS 30 NY Tri-State Aetna PPO 750 NY Tri-State Aetna PPO 1000 NY Tri-State Aetna Out-of-Area PPO Physician Hospital Services Physician Office Visit $30/visit $50/visit $20/visit $30/visit $25/visit $40/visit $25/visit $50/visit 60% covered after Surgery Outpatient $75/visit (facility only) 90% covered after 80% covered after 80% covered after 60% covered after Hospital Inpatient Room and Board Surgery Anesthesia Drugs/Supplies after $600/confinement 90% covered after 80% covered after 80% covered after 60% covered after Emergency Room (Copay waived if admitted) $100/visit $150/visit $150/visit $250/visit $100/visit $150/visit $150/visit $250/visit Urgent Care $75/visit $75/visit $75/visit $75/visit 60% covered after Pregnancy Maternity Care Prenatal Care and Inpatient Inpatient: $600 copay/confinement Inpatient: 90% covered after Inpatient: 80% covered after Inpatient: 80% covered after 60% covered after Prescription Drugs Retail Pharmacy In-Network (30-day supply if not specified) Dollar amounts listed are generic/formulary brand/ non-formulary brand Mail-Order Program In- Network (90-day supply if not specified; out-of-network not covered) Dollar amounts listed are generic/formulary brand/ non-formulary brand $10/$30/$50 $10/$30/$50 $10/$30/$50 $10/$35/$60 $20/$60/$100 $20/$60/$100 $20/$60/$100 $20/$70/$120 Specialty Pharmacy (Includes many specialty drugs. Call your carrier for more information.) Refer to COC or contact Aetna for further details Refer to your COC or contact Aetna for further details Refer to your COC or contact Aetna for further details 25% of prescription cost, up to $250/prescription, with prior authorization 8/28/2014 7
Aetna PPO 2000 NY Tri-State Plan Basics Regional Plan Names Plan Locations Carrier Network Aetna PPO 2000 NY Tri-State CT, NJ, NY Aetna Managed Choice POS Open Access Plan Features Calendar-Year Deductible (Deductible applies where specifically stated) * (does not apply if the employee and any family members are enrolled in the plan) Deductible Carryover (Any covered expenses incurred in the last 3 months of a Calendar Year that applytoward that year's network/out-of-network Calendar Year will also count toward the following year'snetwork/out-of-network Calendar Year.) Calendar-Year Out-of-Pocket Expense Maximum (Includes, coinsurance and medical/rx copays unless otherwise stated) * (does not apply if the employee and any family members are enrolled in the plan) Lifetime Benefits Maximum $2,000/person; $5,000/family $2,500/person; $6,250/family Yes $6,000/person; $12,000/family $8,000/person; $20,000/family Unlimited Routine Health Maintenance Preventive Care Well-woman Well-baby Well-man (Includes annual Pap smear, routine mammogram, and annual prostate exam) Vision Testing Hearing Testing Not Covered Physician Hospital Services Physician Office Visit Surgery Outpatient Hospital Inpatient Room and Board Surgery Anesthesia Drugs/Supplies Emergency Room (Copay waived if admitted) Urgent Care $30/visit $60/visit 80% covered after 80% covered after $150/visit $150/visit $75/visit 8/28/2014 8
Aetna PPO 2000 NY Tri-State Pregnancy Maternity Care Prenatal Care and Inpatient Inpatient: 80% covered after Prescription Drugs Retail Pharmacy In-Network (30-day supply if not specified) Dollar amounts listed are generic/formulary brand/ non-formulary brand Mail-Order Program In-Network (90-day supply if not specified; out-of-network not covered) Dollar amounts listed are generic/formulary brand/ non-formulary brand Specialty Pharmacy (Includes many specialty drugs. Call your carrier for more information.) $10/$30/$50 $20/$60/$100 Refer to your COC or contact Aetna for further details 8/28/2014 9
Dental Plans Aetna DMO Delta Dental DMO Aetna Dental 50 Aetna Dental 100 Plan Basics Regional Plan Names Aetna DMO Group Aetna DMO Optional DeltaCare USA DMO Group DeltaCare USA DMO Optional Aetna Dental 50 Group Aetna Dental 50 Optional Aetna Dental 100 Group Aetna Dental 100 Optional Plan Locations Nationwide, except AL, AK, AR, LA, ME, MS, MT, ND, NH, SC, SD, VT, WY Nationwide, except AK, ID, IA, MA, MN, MT, NE, ND, SD, VT, VA, WY Nationwide* Nationwide* Carrier Network Dental Maintenance Organization (DMO) DeltaCare USA Dental PPO/PDN with PPO II Network Dental PPO/PDN with PPO II Network Plan Features Notes on Availability Service areas may not be available in all ZIP codes for DMO/PPO plans No benefits are available outside the Dental Maintenance Organization (DMO) network of providers No benefits are available outside the Delta Care USA network of providers You can use any licensed dentist you receive a discount when you use a dentist who participates in the PPO/PDN with PPO II network You can use any licensed dentist you receive a discount when you use a dentist who participates in the PPO/PDN with PPO II network Calendar-Year Deductible (Required before plan pays benefits) None None $50/person; $150/family $100/person; $300/family $100/person; $300/family $150/person; $450/family Calendar-Year Benefit Maximum None None $1,500/person $1,000/person Diagnostic Preventive Routine Checkups, Cleanings, X-rays, and Diagnostic Visits Not covered Not covered 100% UCR covered 100% UCR covered (Limitations may apply refer to the EOC booklet for details) Basic Services Fillings and Oral Surgery $0 $75/visit depending on the services rendered Fillings: $0 $85/visit depending on the services rendered Oral Surgery: $0 $110/visit depending on the services rendered 90% covered after Periodontics $21 $140/visit depending on the services rendered $15 $280/visit depending on the services rendered 90% covered after Endodontics $0 $246/visit depending on the services rendered $0 $280/visit depending on the services rendered 90% covered after Crowns Cast Restorations Crowns, Inlays, Onlays, and Bridges $0 $220/visit depending on the services rendered $0 $240/visit depending on the services rendered 65% covered after 50% covered after 8/28/2014 10
Aetna DMO Delta Dental DMO Aetna Dental 50 Aetna Dental 100 Prosthodontics Dentures $10 $240/visit depending on the services rendered $10 $210/visit depending on the services rendered 65% covered after 50% covered after Orthodontics Orthodontics $2,000 for 24-month treatment plan** Lifetime Maximum $1,700 Child $1,900 Adult for 24-month treatment plan** Lifetime Maximum 50% covered after $50 orthodontia $50 orthodontia Not covered (Up to $1,500/person/lifetime) * In Texas, the coverage level for out-of-network benefits is the same as for in-network benefits for the Aetna, Delta Dental, Guardian and MetLife dental plans due to state regulations. ** Includes initial examination, diagnosis, consultation, initial banding, 24 months of active treatment, debanding, and the retention phase of treatment. The treatment phase includes the initial construction, placement, and adjustments to retainers and office visits for a maximum of 24 months. 8/28/2014 11
Delta Dental 50 Delta Dental 100 Guardian Dental 50 Guardian Dental 100 Plan Basics Regional Plan Names Delta Dental 50 Group Delta Dental 50 Optional Delta Dental 100 Group Delta Dental 100 Optional Guardian Dental 50 Group Guardian Dental 50 Optional Guardian Dental 100 Group Guardian Dental 100 Optional Plan Locations Nationwide* Nationwide* Nationwide* Nationwide* Carrier Network Delta Dental PPO Network Delta Dental PPO Network DentalGuard Preferred PPO DentalGuard Preferred PPO Plan Features Notes on Availability Service areas may not be available in all ZIP codes for DMO/PPO plans You can use any licensed dentist you receive a discount when you use a dentist who participates in the Delta Dental PPO network You can use any licensed dentist you receive a discount when you use a dentist who participates in the Delta Dental PPO network You can use any licensed dentist you receive a discount when you use a dentist who participates in the DentalGuard Preferred PPO network You can use any licensed dentist you receive a discount when you use a dentist who participates in the DentalGuard Preferred PPO network Calendar-Year Deductible (Required before plan pays benefits) $50/person; $150/family $100/person; $300/family $50/person; $150/family $100/person; $300/family $100/person; $300/family $150/person; $450/family $100/person; $300/family $150/person; $450/family Calendar-Year Benefit Maximum $1,500/person $1,000/person $1,500/person $1,000/person Diagnostic Preventive Routine Checkups, Cleanings, X-rays, and Diagnostic Visits 100% UCR covered 100% UCR covered 100% UCR covered 100% UCR covered Basic Services Fillings and Oral Surgery 90% covered after 90% covered after Periodontics 90% covered after 90% covered after Endodontics 90% covered after 90% covered after Crowns Cast Restorations Crowns, Inlays, Onlays, and Bridges 65% covered after 50% covered after 65% covered after 50% covered after Prosthodontics Dentures 65% covered after 50% covered after 65% covered after 50% covered after 8/28/2014 12
Delta Dental 50 Delta Dental 100 Guardian Dental 50 Guardian Dental 100 Orthodontics Orthodontics 50% covered after $50 orthodontia Not covered 50% covered after $50 orthodontia Not covered $50 orthodontia $50 orthodontia (Up to $1,500/person/lifetime) (Up to $1,500/person/lifetime) * In Texas, the coverage level for out-of-network benefits is the same as for in-network benefits for the Aetna, Delta Dental, Guardian and MetLife dental plans due to state regulations. 8/28/2014 13
MetLife Dental 50 MetLife Dental 100 Plan Basics Regional Plan Names MetLife Dental 50 Group MetLife Dental 50 Optional MetLife Dental 100 Group MetLife Dental 100 Optional Plan Locations Nationwide*, except FL Nationwide*, except FL Carrier Network MetLife Preferred Dentist Program Plus(PDP Plus) Network MetLife Preferred Dentist Program Plus(PDP Plus) Network Plan Features Notes on Availability Service areas may not be available in all ZIP codes for DMO/PPO plans Calendar-Year Deductible (Required before plan pays benefits) You can use any licensed dentist you receive a discount when you use a dentist who participates in the PDP Plus network $50/person; $150/family $100/person; $300/family You can use any licensed dentist you receive a discount when you use a dentist who participates in the PDP Plus network $100/person; $300/family $150/person; $450/family Calendar-Year Benefit Maximum $1,500/person $1,000/person Diagnostic Preventive Routine Checkups, Cleanings, X-rays, and Diagnostic Visits 100% UCR covered 100% UCR covered Basic Services Fillings and Oral Surgery Periodontics Endodontics 90% covered after 90% covered after 90% covered after Crowns Cast Restorations Crowns, Inlays, Onlays, and Bridges 65% covered after 50% covered after Prosthodontics Dentures 65% covered after 50% covered after 8/28/2014 14
MetLife Dental 50 MetLife Dental 100 Orthodontics Orthodontics 50% covered after $50 orthodontia $50 orthodontia (Up to $1,500/person/lifetime) Not covered * In Texas, the coverage level for out-of-network benefits is the same as for in-network benefits for the Aetna, Delta Dental, Guardian and MetLife dental plans due to state regulations. 8/28/2014 15
Vision Plans Aetna Vision Plan Aetna Vision Plus Plan VSP: Vision Plan VSP: Vision Plus Plan Plan Basics Regional Plan Names Aetna Vision Plan Aetna Vision Plus Plan VSP: Vision Plan VSP: Vision Plus Plan Plan Locations Nationwide Nationwide Nationwide Nationwide Carrier Network Aetna Network with EyeMed Providers Aetna Network with EyeMed Providers VSP Choice Network VSP Choice Network Plan Features Copay Schedule Exam: $10 Exam: $10 Exam: $10 Exam: $10 Materials: $25 Materials: $25 Materials: $25 Materials: $25 Exam: $10 Exam: $10 Materials: $25 Materials: $25 Frequency of Services Eye Examinations Every 12 months Every 12 months Every 12 months Every 12 months Replacement Lenses Every 12 months Every 12 months Every 12 months Every 12 months Frames Every 24 months Every 12 months Every 24 months Every 12 months Exam Eye Exam Routine Eye Exam: $10 Routine Eye Exam: $10 Routine Eye Exam: $10 Routine Eye Exam: $10 Contact Eye Exam including materials: $10 then $120 allowance Contact Eye Exam including materials: $10 then $200 allowance Contact Eye Exam including materials: $10 then $120 allowance Contact Eye Exam including materials: $10 then $200 allowance Routine Eye Exam: $45 Contact Eye Exam: Not Covered Routine Eye Exam: $50 Contact Eye Exam: Not Covered Routine Eye Exam: $10 copay then $45 allowance Contact Eye Exam: Not Covered Routine Eye Exam: $10 copay then $50 allowance Contact Eye Exam: Not Covered Lenses Single Vision Lenses (Depends on prescription and add-ons) $45 allowance $50 allowance $45 allowance $50 allowance Bifocal Lenses (Depends on prescription and add-ons) $65 allowance $75 allowance $65 allowance $75 allowance Trifocal Lenses (Depends on prescription and add-ons) $85 allowance $100 allowance $85 allowance $100 allowance 8/28/2014 16
Aetna Vision Plan Aetna Vision Plus Plan VSP: Vision Plan VSP: Vision Plus Plan Frames Moderate Frames (Depends on style and brand) $130 allowance, then 20% discount $150 allowance, then 20% discount then $130 allowance then 20% discount then $150 allowance then 20% discount $47 allowance $75 allowance $47 allowance $75 allowance Costco/Walmart/Sam's Club: $70 allowance Costco/Walmart/Sam's Club: $100 allowance Contact Lenses Contact Lenses (Depends on prescription and add-ons) Conventional lenses: $120 allowance (paid in full if medically necessary), then 15% discount Conventional lenses: $200 allowance (paid in full if medically necessary), then 15% discount Conventional lenses: $120 allowance (paid in full if medically necessary), then 15% discount Conventional lenses: $200 allowance (paid in full if medically necessary), then 15% discount Conventional lenses: $105 allowance; ($150 if medically necessary) Conventional lenses: $200 allowance; ($210 if medically necessary) Conventional lenses: $105 allowance; ($150 if medically necessary) Conventional lenses: $200 allowance; ($210 if medically necessary) 8/28/2014 17