Orange County Government
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  Certificate of Benefits
 

 
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Plan Frequencies Exam every 12 months
Lenses every 12 months
Frames every 12 months

Copayment for each member at the time of service
Exam: $5
Lenses and/or frames: $15

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
Progressive Lenses    
Levels I-III
$25
N/A
Levels IV
$45
N/A
Contact Lenses    
Elective (exam and lenses)** Exam +
$120
Exam +
$120
Medically necessary* Paid in full $210
Frame $45 wholesale $45 retail
Lasik*** Members will receive a discount if services are rendered by a TLC Network provider and they will pay no more than $1800/eye. No benefit
  Discount Only No Benefit

* Medically necessary (prior authorization required) is the following situations:

1. Following cataract surgery;
2. When visual acuity cannot be corrected to 20/70 in the better eye except by their use;
3. Anisometropia of greater than 3.50 diopters and aesthenopia or diplopia, with spectacles;
4. Keratoconus diagnosis where contact lenses are treatment of choice;
5. Monocular aphakia and/or binocular aphakia where the doctor certifies contact lenses are medically necessary for safety and rehabilitation to a productive life.

**Benefits include (1) The cost of an annual vision exam, subject to the copayment; and (2) the cost of contact lenses, any fitting costs and follow-up visit up to the maximum, not subject to the copayment. This is in lieu of all other benefits and not available when benefits for eyeglasses are received.

***The frame allowance is based on a wholesale amount. If the actual wholesale cost exceeds the wholesale frame allowance, you will be required to pay twice the wholesale difference.

This schedule shows only a few of the covered procedures. This schedule is intended for comparison purposes only. The benefits of each plan will be determined by the contract. For a complete listing of benefits and exclusions and limitations, please reference your certificate of coverage.