More than 92% of our plan members choose a network doctor from our List
of Member Doctors. Doing so means getting the greatest value from the plan
at the least out-of-pocket expense. Services and materials are provided on a
prepaid basis, and the plan pays network doctors directly.
Plan members may use non-network doctors if they wish. In this case, they
pay their doctor at the time of the visit and submit receipts to us for
reimbursement. Benefits are paid according to a reimbursement schedule. The
following shows the maximum allowances for services and materials depending
on whether or not a plan member uses a network doctor:
Copayment for each member at the time of service
Exam: $10
Lenses and/or frames: $15
Network Doctor
(After copayments/
up to plan limits)
Non-network
Eye Exam
Paid in full
$30
Lenses (per pair)
Single
Paid in full
$20
Bifocal
Paid in full
$40
Trifocal
Paid in full
$60
Lenticular
Paid in full
$80
Progressives
Paid in full
$100
Contact Lenses
Elective (fitting, follow-up & lenses)**
$120
$100 allowance for exam and lenses
Medically necessary*
Paid in full
$150 allowance for exam and lenses
Frame
Paid in full
Covered up to $45 retail
*Medically
necessary (prior authorization required) is defined as 1.) following
cataract surgery w/o intraocular lens; 2.) correction of extreme visual
acuity problems not correctable with glasses; 3.) anisometropia greater
than 5.00 diopters and asthenopia or diplopia, with spectacles; 4.)
Keratoconus; or 5.) moncular aphakia and/or binocular aphakia where the
doctor certifies contact lenses are medically necessary for safety and
rehabilitation to a productive life.
**This
allowance is paid with the same frequency as lenses, in place of lens
and frame benefit.
The amounts shown are maximum benefits. The actual
benefit amount the plan will reimburse to a plan member for non-network
doctors will be the least of: the maximum shown in the schedule; the
amount actually charged; or the amount a doctor usually charges a private
patient.
The availability of services under the non-network reimbursement schedule
is subject to the same time limits as those for network services. The plan
pays non-network benefits in place of services from a network doctor.
Out-of-State Services
In-network services are available through a nationwide network of
participating doctors. If plan members travel or move to another state,
their plan goes with them. They simply request a List of Member Doctors
for that area along with the benefit form, and as long as they remain
eligible, they will receive the same benefits as they would in their home
state.
