Page 14 - B12797-ITDR-Enrollment-Guide-2020

2020 Vision plans (for Medicare and non-Medicare eligible retirees)
Included in Kaiser Permanente Medical Plans - Kaiser Permanente Vision Benefits
Traditional Plan
Medical plan benefits include a $150 allowance every 24 months for eyewear purchased at Kaiser plan medical offices or Kaiser plan optical sales offices. You pay the amount in excess of the $150 allowance.
Kaiser Permanente Senior Advantage Plan
Medical plan benefits include routine eye exams with a plan optometrist. You pay a $15 copay per visit. It also includes a $150 allowance every 24 months for eyewear purchased at plan medical offices or plan optical sales offices. You pay the amount in excess of the $150 allowance.
Aetna VisionSM Preferred Plan - stand-alone vision plan
60,000+ vision providers1 that participate — including neighborhood eye doctors, as well as your favorite chains such as LensCrafters®, Pearle Vision®, Sears Optical®, Target Optical®, and JCPenney Optical.
Monthly premium
Retiree only Retiree + spouse Retiree + child(ren) Retiree + family
Exams
$7.32 $14.46 $15.22 $23.17
In network
Out of network
Out of network
Use your exam coverage once every calendar year.
Routine/comprehensive eye exam Standard contact lens fit/follow-up Premium contact lens fit/follow-up
Eyeglass lenses/lens options In network
$10 copay
$25 reimbursement
You pay discounted fee of $40
Not covered
You pay 90% of retail
Not covered
Use your lens coverage once every calendar year to purchase either one pair of eyeglass lenses or one order of contact lenses.
Single vision lenses
Bifocal vision lenses
Trifocal vision lenses
Lenticular vision lenses
Standard progressive vision lenses
Premium progressive vision lenses1
UV treatment
Tint (solid and gradient)
1EyeMed provider data as of December 2013.
$10 copay
$20 reimbursement
$10 copay
$40 reimbursement
$10 copay
$65 reimbursement
$10 copay
$65 reimbursement
$75 copay
$40 reimbursement
$75 Copay + [(80% of Charge) less $120 allowance]
$40 reimbursement
You pay discounted fee of $15
Not covered
You pay discounted fee of $15
Not covered
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