Proprietary 8-23 18 Exclusions n Plano lenses (lenses with refractive correction of less than ± .50 diopter) n Two pairs of glasses instead of bifocals n Refitting of contact lenses after the initial (90-day) fitting period See the Benefits Certificate of Coverage on the Empyrean website for additional details. The following is a chart showing coverage with a Superior Network Provider. Visit www.mybenefits.metlife.com for details if you plan to see a provider other than a network provider. Coverage with a participating retail chain may be different. Once your benefit is effective, visit www.mybenefits.metlife.com for details. In the event of a conflict between this information and the applicable contract with the Vision Plan, the terms of the contract will prevail. Benefits may vary by location. The terms of your benefit plans are governed by legal documents. Refer to your Vision Plan SPD for more details and plan limitations. Benefit In-Network Low Option High Option Comprehensive Eye Exam $25 copay; every calendar year $25 copay; every calendar year Contact Lens Exam $30 copay; every calendar year $30 copay; every calendar year Lasik Benefits* Yes Yes Hearing Benefits* Yes Yes Eyeglass Lenses n Single Vision n Bifocal n Trifocal n Lenticular Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Eyeglass Frames n Retail frame n Enhanced frame Every other calendar year $180 allowance $205 allowance Every calendar year $200 allowance $225 allowance Elective Contact Lenses $180 allowance in lieu of eyeglasses $200 allowance in lieu of eyeglasses Necessary Contact Lenses Covered in full Covered in full Lens Options* n Anti-reflective coating – Standard – Premium – Ultra – Ultimate n Polycarbonate lenses n Tints n Progressive lenses – Standard – Premium – Ultra – Ultimate n UV coating n Polarized lenses n Scratch coating Member Out of Pocket Cost $50 $70 $85 $120 $40 adults/$0 children Solid tints $15; Gradient tints $18 Covered in full $110 $150 $225 $12 $75 $15 Member Out of Pocket Cost Covered in full $70 $85 $120 $40 adults/$0 children Solid tints $15; Gradient tints $18 Covered in full $110 $150 $225 Covered in full $75 $15 * Not available at all locations; verify coverage prior to service.
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