/ Location Code / / MI ( ) - - - Husband MI - - / / Husband MI - - / / Husband MI - - / / Husband MI - - / / / / Last Name* Gender*: Male For additional dependents, please complete a second form. First Name* Social Security Number Date of Birth* Employee Signature*: Dependent 3 Change Type*: Add Term Update Date*: Add Term Update Relationship*: Wife Son Daughter Domestic Partner Dependent 2 Change Type*: Date of Birth* Social Security Number Dependent 1 Relationship*: Daughter Change Type*: Add Term ^Last four digits of Employee's Social Security Number are required. Underwritten by Fidelity Security Life Insurance Company of Kansas City, Missouri Employee Email Address: Zip Code* Last Name* Please print in all capital letters using blue or black ink. Please complete all sections. Enrollment/Change Form Date of Birth* First Name* Employee Information: to be completed by Employee Employer Information: to be completed by Employer Group Number* Subgroup* Gender* Male Female Term Update City* Phone Number Street Address* Social Security Number* ^ Required sections are marked with an *. Domestic Partner Last Name* Gender*: Male Female Dependent 4 Change Type*: Add Term Update Relationship*: Wife Son Daughter Last Name* Gender*: Male Female First Name* Social Security Number Date of Birth* Female Relationship*: ^Date set by employer in accordance with EyeMed proposal. Employer also sets effective date for new adds during contract period. First Name* Social Security Number Date of Birth* Employer Name* State* Member ID: Wife Son Daughter Domestic Partner Male Female Last Name* Wife Son Domestic Partner Gender*: Update Family Information: to be completed by Employee. Only eligible dependents may be enrolled. Change Type*: Add First Name* M E E / N G I N E E R I N G P C 2 0 2 2 1 0 2 6 5 7 3 1 0 0 1
Transcript
/
Location Code
/ /
MI
( ) -
- -
Husband
MI
- - / /
Husband
MI
- - / /
Husband
MI
- - / /
Husband
MI
- - / /
/ /
Last Name* Gender*:
Male
For additional dependents, please complete a second form.
First Name* Social Security Number Date of Birth*
Employee Signature*:
Dependent 3Change Type*: Add Term Update
Date*:
Add Term Update
Relationship*: Wife Son Daughter Domestic PartnerDependent 2
Change Type*:
Date of Birth*Social Security Number
Dependent 1Relationship*: Daughter
Change Type*: Add Term
^Last four digits of Employee's Social Security Number are required.
Underwritten by Fidelity Security Life Insurance Company of Kansas City, Missouri
Employee Email Address:
Zip Code*
Last Name*
Please print in all capital letters using blue or black ink. Please complete all sections.
Enrollment/Change Form
Date of Birth*
First Name*
Employee Information: to be completed by Employee
Employer Information: to be completed by Employer
Group Number* Subgroup*
Gender*
Male Female
Term Update
City*
Phone Number
Street Address*
Social Security Number*^
Required sections are marked with an *.
Domestic PartnerLast Name* Gender*:
Male Female
Dependent 4Change Type*: Add Term Update
Relationship*: Wife Son Daughter
Last Name* Gender*:
Male Female
First Name* Social Security Number Date of Birth*
Female
Relationship*:
^Date set by employer in accordance with EyeMed
proposal. Employer also sets effective date for new adds
during contract period.
First Name* Social Security Number Date of Birth*
Employer Name*
State*
Member ID:
Wife Son Daughter Domestic Partner
Male Female
Last Name*Wife Son Domestic Partner
Gender*:
Update
Family Information: to be completed by Employee. Only eligible dependents may be enrolled.
Change Type*: Add
First Name*
M E E/ N G I N E E R I N G P C 2 0 2 2
1 0 2 6 5 7 3 1 0 0 1
M/E Engineering PC
SUMMARY OF BENEFITS
VISION CARE SERVICESIN-NETWORKMEMBER COST
OUT-OF-NETWORK MEMBER REIMBURSEMENT
7
EXAM SERVICESExam $10 copay Up to $40Retinal Imaging Up to $39 Not covered
CONTACT LENS FIT AND FOLLOW-UPFit and Follow-up - Standard $40 Not coveredFit and Follow-up - Premium 10% off retail price Not covered
FRAMEAny available frame at provider location $0 copay; 20% off balance over $130 allowance Up to $91
STANDARD PLASTIC LENSESSingle Vision $25 copay Up to $30Bifocal $25 copay Up to $50Trifocal $25 copay Up to $70Lenticular $25 copay Up to $70Progressive - Standard $80 copay Up to $50Progressive - Premium Tier 1 $110 copay Up to $50Progressive - Premium Tier 2 $120 copay Up to $50Progressive - Premium Tier 3 $135 copay Up to $50Progressive - Premium Tier 4 $200 copay Up to $50
LENS OPTIONSAnti Reflective Coating - Standard $45 copay Up to $5Anti Reflective Coating - Premium Tier 1 $57 copay Up to $5Anti Reflective Coating - Premium Tier 2 $68 copay Up to $5Anti Reflective Coating - Premium Tier 3 $85 copay Up to $5
Photochromic - Non-Glass $75 Not coveredPolycarbonate - Standard $40 Not covered
Scratch Coating - Standard Plastic $15 Not coveredTint - Solid or Gradient $15 Not coveredUV Treatment $15 Not covered
All Other Lens Options 20% off retail price Not covered
CONTACT LENSESContacts - Conventional $0 copay; 15% off balance over $130 allowance Up to $91Contacts - Disposable $0 copay; plus balance over $130 allowance Up to $91Contacts - Medically Necessary $0 copay; Paid-In-Full Up to $210OTHERHearing Care from Amplifon NetworkCare Discounts on hearing exam and aids; call 1.877.203.0675 Not coveredLasik or PRK from U.S. Laser Network 15% off retail or 5% off promo price; call 1.800.988.4221 Not covered
FREQUENCIES (Plan allows member to receive either contacts and frame, or frames and lens services)
Exam Once every plan yearFrame Once every other plan yearLenses Once every plan yearContacts Once every plan year
Additional discounts
40%OFF
Complete pairof prescriptioneyeglasses
20%OFF
Non-prescriptionsunglasses
These discounts are not insured benefits and are for in-network providers only. For vision plans with qualified materials benefit only. Not applicable for exam only vision plans.
Take a sneak peek before enrolling
• You’re on the Insight Network
• For a complete list of in-network providersnear you, use our Enhanced ProviderLocator on eyemed.com or call 1.866.804.0982
• For LASIK providers, call 1.800.988.4221
QL-0000015920Premium progressives and premium anti-reflective designations are subject to annual review by EyeMed’s Medical Director and are subject to change based on market conditions. Fixed pricing is reflective of brands at the listed product level. All providers are not required to carry all brands at all levels. Benefits are not provided from services or materials arising from: 1) Orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; 2) Medical and/or surgical treatment of the eye, eyes or supporting structures; 3) Any eye or Vision Examination, or any corrective eyewear required by a Policyholder as a condition of employment; Safety eyewear; 4) Services provided as a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof; 5) Plano (non-prescription) lenses; 6) Non-prescription sunglasses; 7) Two pair of glasses in lieu of bifocals; 8) Services or materials provided by any other group benefit plan providing vision care 9) Services rendered after the date an Insured Person ceases to be covered under the Policy, except when Vision Materials ordered before coverage ended are delivered, and the services rendered to the Insured Person are within 31 days from the date of such order. 10) Lost or broken lenses, frames, glasses, or contact lenses will not be replaced except in the next Benefit Frequency when Vision Materials would next become available. Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Standard/Premium Progressive lens not covered-fund as a Bifocal lens. Standard Progressive lens covered-fund Premium Progressive as a Standard. Benefit allowance provides no remaining balance for future use within the same benefit year. Fees charged for a non-insured benefit must be paid in full to the Provider. Such fees or materials are not covered.Underwritten by Fidelity Security Life Insurance Company of New York, Brewster, New York. Fidelity Security Life Policy number VCN-1, form number MN-1/MN-2/MN-3. This is a snapshot of your benefits. The Certificate of Insurance is on file with your employer.
Welcome to EyeMedYOU’LL LIKE IT HERE
Welcome to a whole new world of vision care. Whether you’re a vision benefits veteran or a newbie, get ready for an unrivaled experience. You’ve joined an exclusive club – if you can call more than 55 million members exclusive.
We don’t want you to miss a moment.
ENJOY MORE CHOICE
We’re about to set you loose in a huge network with no restrictions. See the doctors, options and brands you want. The who, what, where and when are all up to you. Your vision is too important for limits. You should be free to see your best, look your best and be your best. With EyeMed, you are.
ENJOY MORE EX TR AS
We want you to feel like your vision benefits cater to you. Because they do. We’re out to wow you with members-only savings and an eye-opening experience. You’ll never pay sticker price for eyewear and you won’t get unexpected bills for doctor visits. That’s just how life is for an EyeMed member.
ENJOY MORE GUIDANCE
Here’s why EyeMed is more than vision benefits: we want you to see better and feel better. That’s what being a member is all about, right? So we go out of our way to make your benefits easy to understand – and even easier to use. We build the tools. We personalize them. And if it’s not enough, we have a live call center that’s eager to please.
SEE THE GOOD STUFF
Register on eyemed.com or grab the member app (App Store or Google Play) now
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KEEP UP WITH EYEMED TEX T ALERTS
Get just-in-time updates and reminders, tips to maximize your benefits and extra ways to save money. Call 844.873.7853 to opt in. Be sure to have your 9-digit member ID handy.
INNOVATIVE ANSWERS FOR SMART SHOPPERS
Smart tools for savvy shoppersKNOW BEFORE YOU GO
With EyeMed’s Know Before You Go out-of-pocket cost estimator, you can get a feel for what you might pay before you even step foot into a store or doctor’s office. The tool includes simple, clear definitions of common products and add-ons, all while calculating a range of costs with each click. So you can feel confident from check-in to check-out.
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1 Log into eyemed.com and find our Know Before You Go out-of-pocket cost estimator.
2 Pick the type of exam you'll need. Just need glasses or contacts? Take a look at Step 3.
3 Choose from a variety of lens types, options and add-ons. Plus, get detailed descriptions of each product so you feel confident in your choices.
4 The best part? You get a range of costs based on your choices and applied vision benefits. We do the math so you stay in-the-know before you go.
Register on eyemed.com to try Know Before You Go today
Fresh look. Same great benefits.GET THE WHOLE PICTURE
Our revamped Member Web is the place for all things vision— a one-stop shop where you can manage your benefits whenever you want. And now, it’s got an all-new look designed to make things easier, faster and more convenient for you.
YOU’LL LIKE WHAT YOU SEE
What can you do with the new Member Web? Simple: just about everything, all in one place.
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• Find an in-network eye doctor with our refreshed Provider Locator
• View your Savings Dashboard to see how much you’ve saved with your benefits
• Estimate out-of-pocket costs before your visit
• Browse your vision benefits and view claims
• Grab special offers curated just for you
• Take a look at your ID card• Discover helpful guides,
resources and FAQs — even while traveling abroad
SEE FOR YOURSELF
Log in or create a new Member Web account at eyemed.com/member
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EXPERIENCE MORE: MOBILE ACCESS
HOW TO: mobilize your vision plan EYEMED MEMBERS APPOur member app was the first of its kind. But innovation — like your life — never stops. The EyeMed Members App is packed with ahead- of-the-game resources wherever you are. Before, during and after your eye appointment.
Get the latest EyeMed Members App:
1. DOWNLOAD — Search “EyeMed Members” in your App store, iTunes or Google Play.
2. OPEN — You can use some features right away; others unlock once you register.
3. REGISTER — You’ll need your member ID or the last four digits of your social security number.
4. LOG IN — If you’ve already registered on eyemed.com, you can log onto the app the same way.
Ready when you download
Unlocked when you register
Find nearby network providers
On-the-fly appointment scheduling
Turn by turn directions and map
Eye exam and contact lens reminders
Electronic ID card for office visits
Save vision prescriptions*
Benefit plan details
Answers to common questions
Special offers and discounts
Direct line to EyeMed support
SEE THE GOOD STUFF
Register on eyemed.com or grab the member app (App Store or Google Play) now
* Take a picture of your prescription and store it in your app. No need to type in the numbers.
INNOVATIVE ANSWERS FOR SMART SHOPPERS
There’s more in store — onlineIN-NET WORK. ONLINE. OUTSTANDING.
Eyesight changes. How you buy eyewear is changing, too. That’s why you have several online shopping options to go with the thousands of store locations. We believe in benefits without boundaries.
Shop and buy frames, contacts and sunglasses, just like you would in the store — but from your computer, smartphone or tablet. It’s fast, it’s easy and it’s all built into your vision benefits.
CONVENIENT ONLINE SHOPPING
• Choose from hundreds of brand-name frames and contacts.• Instantly apply your in-network benefits at checkout.• Enjoy free shipping and returns.
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lenscrafters.com
targetoptical.com
ray-ban.com
GLASSESCOM glasses.com
contactsdirect.com
DON’T HAVE A CURRENT PRESCRIPTION?
Our provider locator on eyemed.com and the EyeMed Members App will help you find the right place for an eye exam
SEE THE GOOD STUFF
Register on eyemed.com or grab the member app (App Store or Google Play) now
