Monthly rates for: Lakeland Regional Medical Center
Effective date:

Employee:	$5.88
Employee + Family	$14.74

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 (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)	$ 105**	$ 105**
Medically necessary*	Paid in full	$210
Frame	$40 wholesale	$40 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