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|
Plan Frequencies |
Exam every 12 months
Lenses every 12 months
Frames every 24 months |
Copayment for each member at the time of service |
Exam: $5
Lenses and/or frames: $10 |
|
Maximum
Allowances |
Network Doctor
(After copayments/Up to plan limits) |
Non-network
(Copayments apply) |
|
|
|
|
Eye Exam |
Paid in full |
$35 |
Lenses (per pair) |
|
|
Single |
Paid in full |
$25 |
Bifocal |
Paid in full |
$40 |
Trifocal |
Paid in full |
$60 |
Lenticular |
Paid in full |
$100 |
Contact Lenses |
|
|
Elective (exam & lenses)** |
$105 |
$105 |
Medically necessary* |
Paid in full |
$210 |
Frame |
$40 wholesale |
$40 retail |
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