Optional Vision Insurance Coverage

Vision Plan with EyeMed Network Benefits

Spirit’s optional vision plan utilizes the EyeMed Vision Care network. The EyeMed network offers the following features: Savings on eye care and eyewear, quality standards for care and materials and access to thousands of providers nationwide including independent providers and major retail chains.
EYE EXAMINATIONS
Annual eye exams do more than check vision. Exams can detect a variety of conditions, including diabetes, high blood pressure and glaucoma. Early detection and treatment can minimize the effect of these conditions on long-term health. Spirit Vision Insurance covers annual eye exams for maximum health benefits.
USING THE PLAN
| To search for a provider, go to eyemed.com and select the Access Network, or call (866) 289-0614.
| Present your ID card which includes your member ID number.
| The provider will do the rest! There are no claim or authorization forms necessary for in-network benefits.
| For the most accurate information, remember your Plan Number: V00830

This vision plan is only available with Spirit Dental Insurance. If you are searching for stand-along vision insurance, View more vision insurance options

The EyeMed Vision Insurance plan can be added to your Spirit Dental Insurance for an additional amount.

Applicant: $7,  Applicant +1: $14,   Family: $20

In Network Benefits

Eye Examinations
$10 deductible (once every 12 months)
Eye examinations include dilation as determined by the doctor.
Exam Options
Contact lens wearers will pay up to $55 for standard contact lens exam, including fit and follow-up, or receive 10% off retail price for premium contact lens exam, fit and follow-up.
Eyeglass Lenses
$20 deductible (once every 24 months)
Plan covers standard plastic single vision, bifocal or trifocal lenses of any size or power. Lens options are available at additional cost.
Frames
$0 deductible (once every 24 months)
Plan covers a $130 retail allowance that can be applied toward the purchase of any frame available at the provider location. The member will also receive a 20% discount off the balance if selecting a frame that costs more than $130.
Contact Lenses (instead of lenses and frame)
$20 deductible (once every 24 months)
Plan covers a $130 retail allowance that can be applied toward the purchase of conventional or disposable contact lenses.
If the member chooses conventional contact lenses with a retail price over $130, member will receive 15% off the balance. Medically necessary contact lenses are paid in full after the deductible. Replacement contact lenses can be ordered online and conveniently delivered to members’ homes through eyemedcontacts.com.
Additional Discounts
Spirit Vision members will also receive unlimited additional discounts on purchases made at participating provider
| 40% off additional complete pairs of eyeglasses
| 15% off additional purchases of conventional contact lenses
| 20% off non-covered items like cleaning cloths or nonprescription sunglasses

Out of Network Benefits

Members receive the richest benefits when using a participating EyeMed provider. However, the plan includes an out-of-network benefit for services and materials obtained through non-network providers.
Reimbursement Levels
| Eye Examination – Up to $25
| Frames – Up to $40
| Single Vision Lenses – Up to $20
| Bifocal Lenses – Up to $30
| Trifocal Lenses – Up to $40
| Contact Lenses – Up to $60
Using Out-of-Network Benefits
Members must file claims for out-of-network benefits. Members can obtain an out-of-network claim form from EyeMed’s Web site, eyemed.com, or by calling
866-289-0614.
Members will pay for all services and materials in full, then submit the completed claim form with receipts for reimbursement.

Limitations and Exclusions

This plan has the following limitations:
| Vision examinations, lenses and frames more than the
frequency as indicated on the plan summary page.
| This plan does not cover Medically Necessary Contact Lenses more than once in any 24-month period. The treating provider determines if an Insures meets the coverage criteria for this benefit as listed below. This benefit is in lieu of Elective Contact Lenses.
| For Keratoconus where the patient is not
correctable to 20/30 in either or both eyes
using standard spectacle lenses.
| Patients whose vision can be corrected two lines of improvement on the visual acuity chart when compared to best standard spectacle lens correction.
| Anisometropia od 3D or more.
| High Ametropia exceeding -10D or +10D in meridian powers.
| This plan does not cover Orthoptics or vision training and any associated testing.
| This plan does not cover Plane Lenses.
| This plan does not cover non-prescribed Lenses or sunglasses.
| This plan does not cover two pairs of glasses in lieu of Bifocals.
| This plan does not cover replacement of Lenses and Frames that are list of broken outside of the normal coverage intervals.
| This plan does not cover medical or surgical treatment of the eyes or supporting structures.
| This plan does not cover services for claims filed more than one year after completion of the service. An exception is if the Insured shows it was not possible to submit the proof of loss within this period.
| This plan does not cover any procedure not listed on the Schedule of Eye Care Services.

GLASSES.COM AND CONTACTSDIRECT.COM
Members can use glasses.com and contactsdirect.com as an in-network option to purchase frames and contacts.
FOR GLASSES
| Simply send a picture of the prescription. Lenses are available for most prescriptions, including progressives and multifocals.
| Orders are fulfilled and shipped free the following day.
| Once received if you need an adjustment visit any LensCrafters.
FOR CONTACTS
| Select your lenses from a wide selection of top selling brands.
| Contacts will ship as soon as the prescription is verified – most that same day – and for free.
OTHER EYEMED VISION DISCOUNTS

LENS OPTIONS

Coatings and lens treatments can be added for the costs below:

Polycarbonate lenses $40.00
Scratch-Resistant coating $15.00
Solid or gradient tint $15.00
Ultraviolet coating $15.00
Anti-reflective coating $45.00
Standard Progressive
Add on bifocal $65.00
Lens options not listed 20% off retail price

NOTICE: Underwritten by Ameritas Life Insurance Corp. | 5900 O Street Lincoln, NE 6851 This is not a certificate of insurance or guarantee of coverage. Plan designs may not be available in all areas and are subject to individual state regulations. This piece is not for use in New Mexico. This information is provided by Ameritas Life Insurance Corp. (Ameritas Life). Dental, vision and hearing care products (9000 Rev. 03-16 for Group and 9000 Rev. 02-19 for Individual, dates may vary by state) are issued by Ameritas Life. The Dental and Vision Networks are not available in RI. In Texas, our dental network and plans are referred to as the Ameritas Dental Network. Ameritas, the bison design and “fulfilling life” are service marks or registered service marks of Ameritas Life, affiliate Ameritas Holding Company or Ameritas Mutual Holding Company. © 2023 Ameritas Mutual Holding Company.
Based on applicable laws, reduced costs may vary by doctor location.