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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
Materials: $15
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Maximum
Allowances |
Network Doctor
(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 |
|
|
Elective (exam & lenses)** |
Exam
plus $105
|
Exam plus
$105
|
Medically necessary* |
Paid in full |
$210
|
Frame |
$45
wholesale
|
$45 retail
|
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