|
|
 |
| 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
(After copayments/Up to plan limits) |
Non-network
|
|
|
| |
|
|
|
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 |
|
Contact Lenses |
|
|
| Elective (exam & lenses)** |
Exam + $120
|
Exam + $120
|
| Medically necessary* |
Paid in full |
$150
|
| Frame*** |
$50 |
$50 retail
|
|
