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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 $10.00 |
Lenses and/or frames $15.00 |
Maximum Allowances |
Network Doctor
Non-network (After copayments/Up to plan limits) |
Non-network
(copayments apply) |
Eye Exam |
Paid in full |
$35 |
Lenses
(per pair) |
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|
Single |
Paid in full |
$25 |
Bifocal |
Paid in full |
$40 |
Trifocal |
Paid in full |
$60 |
Lenticular |
Paid in full |
$100 |
Contact Lenses |
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Elective (exam & lenses)** |
Exam + $125 |
Exam + $125 |
Medically necessary* |
Paid in full |
$210 |
Frame |
$45 wholesale |
$45 retail |
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