
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
Lenses and/or frames: $15
 |
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) |
|
|
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) |
$150** + Exam |
$150** + Exam |
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 |
|