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Martin County Board of County Commissioners I Employee Benefit Highlights I 2021 <br /> Humana Vision 100 Plan At-A-Glance <br /> Network Insight <br /> Services In-Network Out-of-Network <br /> IEye Exam $10 Copay Up to$30 Reimbursement <br /> Contact Lens Standard Up to$55 Copay Not Covered <br /> Premium-10%Off Retail <br /> Frequency of Services Locate a Provider <br /> Examination T T 12 Months To search fora participating provider, <br /> - -- contact Humana's customer service or <br /> Lenses 12 Months visit www.humana.com.Login or select <br /> —- "Find a doctor or pharmacy"at the <br /> Frames 24 Months bottom of the page.Choose"vision" <br /> - <br /> —� - - - —---- -----, and then choose"Humana Vision <br /> T <br /> Contact Lenses . 12 Months <br /> (Humana Insight Network)".Complete <br /> Lenses the additional search criteria and click <br /> _ "Get Results". <br /> [Single J; , Up to$25 Reimbursement I <br /> IBifocal _ $25 Copay Up to$40 Reimbursement ,' <br /> ' 0 <br /> Trifocal Up to$60 Reimbursement ' <br /> Frames <br /> — — Plan References <br /> Retail Up to$100 Retail Allowance • Up to$50 Reimbursement *Contact lenses are in lieu of spectacle <br /> then 20%Discount Over$100 lenses and a frame. <br /> Contact Lenses* <br /> Non-Elective(Medically Necessary) RequiresPriohAuthorization Up to$200 Reimbursement <br /> _— — - - <br /> Up to$100 Retail Allowance; <br /> Elective(Fitting,follow-up&Lenses) Up to$80 Reimbursement <br /> then 15%Discount Over$100 <br /> ----_. Important Notes <br /> LASIK •Member options,such as LASIK,UV <br /> Contact Humana's Customer Service Discount Programs Not Available coating,progressive lenses,etc.are not <br /> Discount Programs covered in full,but may be available at <br /> for Program Details Out-of-Network <br /> a discount. <br /> -After copay,standard polycarbonate <br /> available at no charge for dependents <br /> • underage 19. <br /> • <br /> 92 <br /> 10 <br /> 0 2016,Gehring Group,Inc.,All Rights Reserved <br />