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Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 Humana Vision 130 Plan At-A-Glance Network Insight Services In-Network Out-of-Network Eye Exam $10 Copay Up to$30 Reimbursement n Standard* Upto$55Allowance Not Covered �„V[ Contact Lens Fit and Follow up premium'" 10%Off Retail Allowance ; Not Covered -- --- Locate a Provider Reimbursement Based on Materials $15 Copay Type of Service To search for a participating provider, --- — _ - _ contact Humana's customer service Retinal Imaging Upto$39Copay Not Covered or visitwww.humana.com.When completing the necessary search Frequency of Services Per Calendar Year criteria,select Humana Insight network. Examination 12 Months Lenses 12 Months 1 [Frames 24 Months l Contact Lenses 12 Months Lenses Plan References Single $15 Copay Up to$25 Reimbursement "Standard Contact lens fitting is ____ _ _ __ __ _ __ , considered single vision standard fitting Bifocal _ $15Copay • Up to$40 Reimbursement with follow up evaluation. 'Trifocal $15 Copay Up to$60 Reimbursement "Premium Contact lens fitting is considered multifocal/monovision or Frames extended/overnight wear,etc,with Up to$130 Retail Allowance Plus follow up evaluation. Allowance Up to$65 Retail Reimbursement 20%Off Balance Over$130 '""Contact lenses ore in lieu of spectacle lenses and a frame. Contact Lenses*** Non-Elective(Medically Necessary) No Charge • Up to$200 Reimbursement Up to$130 Allowance Plus Conventional U to$104 Reimbursement Elective 15%Off Balance P 0 (Evaluation,Fitting Fee and Materials) _ l Disposable Upto$130Allowance Up to$104 Reimbursement Important Notes Member options,such as LASLK,UV coating,progressive lenses,etc.are not covered in full,but may be available at a discount. 123 14 ©2016,Gehring Group,Inc.,All Rights Reserved