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Martin County Board of County Commissioners I Employee Benefit Highlights 12021 Vision Insurance Humana Vision 100 Plan The County offers vision insurance through Humana to benefit-eligible Out-of-Network Benefits employees.The monthly costs for coverage are listed in the premium table Employee and covered dependent(s) may choose to receive services from below and a brief summary of benefits is provided on the following page.For more detailed information about the vision plan,please refer to the carrier's vision providers who do not participate in the Humana Insight network. summary plan document or contact Huinana's customer service. When going out of network,the provider will require payment at the time of appointment.Humana will then reimburse based on the plan's out-of-network reimbursement schedule upon receipt of proof of services rendered. Vision Insurance—Humana Vision 100 Plan Monthly Premiums Calendar Year Deductible Tier of Coverage Employee Cost There is no calendar year deductible. Employee Only t $7.24 j !— -4 ___ Calendar Year Out-of-Pocket Maximum Employee+Family $20.52 T — There is no out-of-pocket maximum.However,there are benefit reimbursement maximums for certain services. In-Network Benefits The vision plan offers employee and covered dependent(s)coverage for routine Humana I Customer Service:(877)398-2980 I www.humana.com eye care, including eye exams, eyeglasses (lenses and frames) or contact Group Number:VS3145 lenses.To schedule an appointment,employee and covered dependent(s)may select any network provider who participates in the Humana Insight network. At the time of service,routine vision examinations and basic optical needs will be covered as shown on the plan's schedule of benefits.Cosmetic services and upgrades will be additional if chosen at the time of the appointment. 91 9 2016,Gehring Group,Inc.,All Rights Reserved