Calvary Chapel of Costa Mesa

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SUMMARY OF BENEFITS

40%OFF

Complete pair of prescription eyeglasses

20% OFF

Non-prescription sunglasses

20% OFF

Remaining balance beyond plan coverage

These discounts are not insured benefits and are for in-network providers only.

• You’re on the Insight Network

• For a complete list of in-network providers near you, use our Enhanced Provider Locator on eyemed.com or call 1-866-804-0982

• For LASIK providers,

call 1-877-5LASER6

Vision Care Services

In-Network Member Cost

Out of Network Reimbursement

Exam With Dilation as Necessary $10 Copay Up to $40

Retinal Imaging Up to $39 N/A

Frames $0 Copay; $200 allowance, 20% off balance over $200 Up to $140

Standard Plastic Lenses

Single Vision $10 Copay Up to $30

Bifocal $10 Copay Up to $50

Trifocal $10 Copay Up to $70

Lenticular $10 Copay Up to $70

Standard Progressive Lens $10 Copay Up to $100

Premium Progressive Lens∆

$30 Copay - $10 Copay, 20% off retail less $120 Allowance Up to $100

Tier 1 $30 Copay Up to $100

Tier 2 $40 Copay Up to $100

Tier 3 $55 Copay Up to $100

Tier 4 $10 Copay, 20% off retail less $120 Allowance Up to $100

Lens Options (paid by the member and added to the base price of the lens)

UV Treatment $15 N/A

Tint (Solid and Gradiant) $15 N/A

Standard Plastic Scratch Coating $15 N/A

Standard Polycarbonate - age 19 and over $40 N/A

Standard Polycarbonate - under age 19 $0 Up to $32

Standard Anti-Reflective Coating $45

N/A

Premium Anti-Reflective Coating∆

$57 - 20% off Retail Price

N/A Tier 1

$57 N/A

Tier 2

$68 N/A Tier 3

20% off Retail Price N/A

Photochromic/Transitions $75

N/A Polarized 20% off Retail Price N/A

Other Add-Ons and Services 20% off Retail Price N/A

Contact Lens Fit and Follow-up (Contact lens fit and two follow-up visits are available once a comprehensive eye exam has been completed.)

Standard Contact Lens Fit & Follow-Up: $40 N/A

Premium Contact Lens Fit & Follow-Up: 10% off Retail Price N/A

Contact Lenses (Contact Lens allowance includes materials only)

Conventional $0 copay, $120 allowance, 15% off balance over $120 Up to $120

Disposable $0 copay, $120 allowance, plus balance over $120 Up to $120

Medically Necessary $0 copay, Paid-In-Full Up to $210

Laser Vision Correction

LASIK or PRK from U.S. Laser Network 15% off the retail price or 5% off the promotional price N/A

Hearing Care

Hearing Health Care from 40% off hearing exams and low price guarantee

Amplifon Hearing Network on discounted hearing aids

Frequency

Examination Once every 12 months

Lenses (in lieu of contact lenses) Once every 12 months

Contacts (in lieu of lenses) Once every 12 months

Frame Once every 24 months

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∆ Premium progressives and premium anti-reflective designations are subject to annual review by EyeMed’s Medical Director and are subject to change based on market conditions. Fixed pricing is reflective of brands at the listed product level . All providers are not required to carry all brands at all levels. Benefits are not provided from services or materials arising from: 1) Orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; 2) Medical and/or surgical treatment of the eye, eyes or supporting structures; 3) Any eye or Vision Examination, or any corrective eyewear required by a Policyholder as a condition of employment; Safety eyewear; 4) Services provided as a result of anyWorkers’ Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof; 5) Plano (non-prescription) lenses; 6) Non-prescription sunglasses; 7) Two pair of glasses in lieu of bifocals; 8) Services or materials provided by any other group benefit plan providing vision care 9) Services rendered after the date an Insured Person ceases to be covered under the Policy, except when Vision Materials ordered before coverage ended are delivered, and the services rendered to the Insured Person are within 31 days from the date of such order. 10) Lost or broken lenses, frames, glasses, or contact lenses will not be replaced except in the next Benefit Frequency when Vision Materials would next become available. Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Standard/Premium Progressive lens not covered-fund as a Bifocal lens. Standard Progressive lens covered-fund Premium Progressive as a Standard. Benefit allowance provides no remaining balance for future use within the same benefit year. Fees charged for a non-insured benefit must be paid in full to the Provider. Such fees or materials are not covered.

Underwritten by Fidelity Security Life Insurance Company of Kansas City, Missouri, except in New York. Fidelity Security Life Policy number VC-19/VC-20, form number M-9083. This is a snapshot of your benefits. The Certificate of Insurance is on file with your employer.

Additional discounts

Take a sneak peek before enrolling

Calvary Chapel of Costa Mesa

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FREEDOM PASS

Feeling free is so youYOUR ST YLE. YOUR PERSONALIT Y. YOUR CHOICE OF FR AMES.

You have a style all your own. Now you can get the frames to match — with a special offer from Sears® Optical and Target® Optical. For $0 out-of-pocket expense get any available frame, any brand — no matter the original retail price point. You’re free to choose any frame in the store at no additional cost to you.

For example, if you purchase a pair of frames that retails for $180, you’re out-of-pocket cost is still $0 — even if you have a $130 frame allowance. That’s a $50 value! Plus, you get extra savings on lenses through your EyeMed vision benefits to complete your look.

WANT MORE? YOU GOT IT

Visit eyemed.com to get special offers from other in-network providers.

PLUS ENJOY SAVINGS ON LENSES

Offer not valid at Sears® Optical stores affiliated with US Vision. This offer is valid for frames only and must be used in conjunction with your EyeMed frame benefit of $130 or more. Lenses are covered based on the benefits outlined in your benefit summary and may include an additional copay. Store associates enter code: 755288

HOW TO REDEEM

Take this flyer to any Sears® Optical or Target® Optical. They’ll handle the rest.

OFFER CODE: 755288

USE IT AT THESE STORES

SHOP THESE TOP BR ANDS AND MORE

GET MORE VALUE WITH

15% OFFstandard LASIK prices *

5% OFFpromotional LASIK prices *

OR

GET MORE CHOICE

Outstanding access to more than 600 locations nationwide

LASIK providers meet stringent credentialing standards

Our members see savings every day with LASIK providers

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This is not insurance. Please note that laser vision correction is an elective procedure, performed by specially trained providers. This discount may not always be available from a provider in your immediate location.

In the state of Texas, EyeMed Vision Care, LLC is the Discount Health Operator offering the LASIK vision discounts.

EyeMed members served through the U.S. Laser Network owned and administered by LCA-Vision, Inc.

*May not be combined with any other discount

**Additional costs may vary; exclusions may apply.

Find a LASIK location at eyemedlasik.com, or call 1-800-988-4221.

• FREE** LASIK exam (more than $100 value)

• FREE** lifetime enhancements on most procedures

Member Tools

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Enroll in EyeMed todayto see the good stuff

EYEMED.COM

Register for an account on eyemed.com to unlock easy. ■■ Find an eye doctor near you■■ Get turn-by-turn directions to the provider of

your choice■■ Schedule appointments on-the-fly■■ View your member ID card■■ See current benefits eligibility and in-network

benefit details■■ Get answers to commonly asked questions■■ Contact us

MAKING LIFE EASIER EVERY DAY

Eye care is an experience. From the day you enroll to the day you find your favorite frames, we’ll be a part of it. Guiding, advising, and helping with two innovative member tools that work together so you get the most from your vision benefits.

EYEMED MEMBERS APP

Our app is like a personal assistant. Download it and get the same helpful features you’d find on eyemed.com — but with upgrades, like the ability to save vision prescriptions, or schedule an exam and contact lens change reminders.

EYEMED TEX T ALERTS

Get the latest vision benefits buzz, right on your phone, right away. Just-in-time updates and reminders, tips to maximize your benefits, extra ways to save money, and more.

There’s more in store – online

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IN-NET WORK. ONLINE. OUTSTANDING. Eyesight changes. How you buy eyewear is changing, too. That’s why EyeMed members enjoy online shopping options to go with the thousands of store locations.

Shop and buy frames, contacts and sunglasses, just like you would in the store — but from your computer, smartphone or tablet. It’s all built into your vision benefits.

ONLINE SHOPPING HIGHLIGHTS

• Choose from the latest eyewear brands.

• Instantly apply your in-network benefits.

• Enjoy free shipping.

DON’T HAVE A CURRENT PRESCRIPTION?

Our provider locator on eyemed.com will help you find the right place for an eye exam.

lenscrafters.com

targetoptical.com

ray-ban.com/eyemed

glasses.com

contactsdirect.com

Enroll in EyeMed today to shop with your benefits online.

HEARING DISCOUNT

FOR THE SWEET SOUNDS OF LIFE

Because we want you to enjoy all life’s sights and sounds, EyeMed members get access to affordable hearing health care discounts through Amplifon, the nation’s largest independent hearing discount network.

YOUR DISCOUNT THROUGH AMPLIFON INCLUDES:

• 40% off hearing exams

• Discounted, set pricing on thousands of hearing aids

• Low price guarantee

• 60-day hearing aid trial period

• Free batteries for 2 years with initial purchase

• 3-year warranty

Enroll in EyeMed today to see – and hear – life to the fullest.

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Special Offers

MEMBERS-ONLY SPECIAL OFFERS

You deserve special savings just for being an EyeMed member. So we've developed a page on eyemed.com that only registered members can see. It’s the latest list of special offers for vision-related products and services. A mix of member discounts and extra savings that give your benefits a boost. So you can keep your eyes healthy and save some cash while you’re at it.

UNLOCK YOUR OFFERS IN MINUTES

Just go to eyemed.com, register and you’re set to shop the savings. And if you have the EyeMed app, pull up the offer at the store—no printing!

New offers are added often, so check before you go.

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■■ Discounts on frames and lenses

■■ Savings on contacts

■■ Exclusive offers from network providers and retailers

■■ Free shipping from online providers

■■ Free vision products, like lens cleaner kits, and more, all from trusted EyeMed network providers