Plan Frequencies
Exam every 12 months
Lenses every 12 months
Frames every 24 months

Copayment for each member at the time of service
Exam -   $15.00
Lenses and/or frames - $15.00

Benefit Schedule

Maximum Allowances		In-Network Doctor (After copayments / Up to plan limits)		Out-of-Network Doctor
Eye Exam		Paid in Full		$35
Lenses (per pair)
Single		Paid in Full		$26
Bifocal		Paid in Full		$40
Trifocal		Paid in Full		$60
Lenticular		Paid in Full		$100
Contact Lenses
Elective (fitting, follow up, & lenses)		$105**		Exam + $105
Medically Necessary*		Paid in Full		$300
Frame***		Covered in full up to plan allowances		$59
Lasik		Members can use independent Lasik provider network doctors to receive a 10% discount from usual and customary prices and pay no more than $1,800 per eye for Conventional Lasik and $2,300 per eye for Custom Lasik.