|
|
 |
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 |
$30 |
| Lenses
(per pair) |
|
|
| Single |
Paid in full |
$20 |
| Bifocal |
Paid in full |
$40 |
| Trifocal |
Paid in full |
$60 |
| Lenticular |
Paid in full |
$100 |
| Contact Lenses |
|
|
| Elective (exam & lenses) ** |
Exam +
$130 |
Exam +
$130 |
| Medically necessary* |
Paid in full |
$150 |
| Frame |
$45 wholesale |
$45 retail |
|
