Copayment for each member at the time of service

Exam: $5
Lenses and/or frames: $10

Maximum Allowances	Network Doctor (After copayments / Up to plan limits)	Non-network (copayments apply)
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 (fitting, follow-up & lenses)	$ 120**	$ 120**
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
	Discount Only	No Benefit