MILA Vision Plan
Benefits Summary
Shown below is the MILA Vision Plan Benefits Summary for eligible active Members, and for those Pensioners age 58 and over who are eligible for benefits in the Premier, Basic, Core or Medicare Wrap-Around Plans and Medicare Advantage Plans and who have not waived participation in the MILA Vision Plan as explained in Section IV, Participation. This chart allows you to see at-a-glance the key Plan Features. The copay amounts are what you will pay when you seek treatment from a Participating Network Vision Care Professional. MILA pays the balance of covered charges under the Plan. If you seek treatment from a vision care professional who does not participate in the EyeMed Vision Care Network that is contracted for the MILA Vision Plan, you also will be responsible for any additional charges made by that vision care professional beyond the negotiated rates that MILA has contracted to pay.
| Exam w/ Dilation |
$10 copay |
$30 |
|
Contact Lens Fit & Follow-up
|
| Standart Contact Lens |
$0 copay |
$40 |
| Premium Contact Lens |
90% retail cost less $40 |
$40 |
|
Frames
|
| Any available frame at provider location |
$15 copay, $100 allowance, then 20% discount |
$40 |
|
Standard Plastic Lenses
|
| Single Vision |
$10 copay |
$25 |
| Bifocal |
$10 copay |
$45 |
| Trifocal |
$10 copay |
$80 |
| Lenticular |
$10 copay |
$80 |
| Standard Progressive Lens |
$10 copay |
$110 |
| Premium Progressive Lens |
See Price List |
$110 |
|
Lens Options
|
| UV Treatment |
$15 |
$0 |
| Tint (solid & gradient) |
$0 |
$15 |
| Standard Plastic Scratch Coating |
$0 |
$15 |
| Standard Polycarbonate- Adults |
$0 |
$40 |
| Standard Polycarbonate- Child <19 |
$0 |
$40 |
| Standard Anti-Reflective Coating |
$45 |
$0 |
| Polarized |
20% off retail |
$0 |
| Photocromatic/Transitions Plastic |
$75 |
$0 |
| Premium Anti-Reflective Coating |
See Price List |
$0 |
| Other Add-ons |
20% off retail |
$0 |
|
Contact Lenses (materials only)
|
| Conventional |
$10 copay, $100 allowance, then 15% discount |
$75 |
| Disposable |
$10 copay, $100 allowance, then balance |
$90 |
| Medically Necessary (See note below table) |
$0 copay, $500 allowance, then balance |
$475 |
|
Laser Vision Correction
|
| Lasik or PRK from US Laser Network |
15% off retail or 5% off promotional |
$0 |
| Additional Pairs Benefit after Plan benefit has been used |
Members receive 40% discount off complete pair of eyeglasses and 15% discount off conventional contacts |
|
Frequency Limits
|
| Examination |
Once every 12 months |
| Lenses or contact lenses |
Once every 12 months |
| Frame |
Once every 24 months |
Note: Contact lenses will be considered “medically necessary” under the Plan only when one of the following conditions exists: (1) Anisometropia of 3D in meridian powers; (2) High Ametropia exceeding -10D or +10D in meridian powers; (3) Keratoconus when the member’s vision cannot be corrected to 20/25 in either or both eyes using standard spectacle lenses; and (4) Vision improvement other than Keratoconus for members whose vision can be corrected two lines of improvement on the visual acuity chart when compared with best corrected standard spectacle lenses. The Vision Plan benefit may not be expanded for other eye conditions even if you or your provider deems contact lenses necessary for other eye conditions or for visual improvement. However, this limitation in the Vision portion of the Plan coverage does not preclude consideration of your condition under the Medical portions of the Plan.
| Member Cost for Premium Progressive Lenses |
| Tier I |
$30 copay |
| Tier II |
$40 copay |
| Tier III |
$55 copay |
| Tier IV |
$10 copay plus 80% of charge less $120 |
| Member Cost for Premium Anti-Reflective Coating |
| Tier I |
$57 copay |
| Tier II |
$68 copay |
| Tier III |
$68 copay |
| Tier IV |
80% of charge |
One can review the list of Premium Progressive lens brands and premium Anti-Reflective Coating brands to determine the Tier of coverage at www.eyemedvisioncare.com or call Customer Service at 1-866-939-3633.
