AtlantiCare 2025 Benefits Booklet

VISION (CONT.)

VISIONPLANCOVERAGE (LOWPLAN)

Welcome.................................... 2 What’s New?............................. 3 How to Enroll........................... 4 Medical....................................... 6 Prescription Drug.................14 FQHC.........................................16 Additional Medical Plan Resources................................17 AtlantiCare Longevity Lifestyle Program................18 Dental.......................................20 Vision.........................................22 Life Insurance........................25 Disability..................................26 Voluntary Offerings.............27 Educational Support & Career Development..........27 Financial Well-being...........28 Health &Wellness................29 Savings.....................................31 Voluntary Benefits...............32 Spending Accounts.............35 Retirement Benefits............36 Contacts...................................38 Legal Notices.........................40 Wellness Checklist...............42

In-Network

Out-of-Network

General Laser Surgery Discount Benefit Frequency Exams

Discount Available

Not Covered

Every 12 Months

Every 12 Months

Lenses

Every 12 Months

Every 12 Months

Frames

Every 24 Months

Every 24 Months

Routine Exams

Covered 100% after $10 Copay

Reimbursed up to $45

$130 allowance, 20% off amount over allowance. Additional $25 frame allowance at select providers.

Frames

$70 allowance

Standard Plastic Lenses Single

Covered 100% after $25 Copay

Reimbursed up to $40

Bifocal

Covered 100% after $25 Copay

Reimbursed up to $60

Trifocal

Covered 100% after $25 Copay

Reimbursed up to $80

Standard Progressive

Up to $55 Member out of pocket cost

Reimbursed up to $50

Contact Lens Benefit

$130 allowance, Conventional: 20% off amount over allowance Disposable: 10% off amount over allowance

Elective Contacts in Lieu of Eyeglasses

$105 Allowance

Necessary Contacts in Lieu of Eyeglasses

Covered in full

$210 Allowance

Lens Options

Solid Plastic: Up to $15 member out of pocket cost. Plastic Gradient: Up to $18 member out of pocket cost

Tint

Applied to corrective lens allowance

Scratch Resistant Coating

Covered in full

Applied to corrective lens allowance

Polycarbonate - Child

Covered in full

Applied to corrective lens allowance

Polycarbonate - Adult

Covered in full

Applied to corrective lens allowance

Employee Only Employee +1 $3.37 Employee and Family $5.72 $1.86

BI-WEEKLY RATES

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