|
|
 |
| Plan Frequencies |
Exam every 12 months
Lenses every 12 months
Frames every 12 months |
|
Copayment for each member at the time of service |
Exam:
$0
Lenses and/or frames: $0
|
 |
| Maximum
Allowances |
Network Doctor
|
Non-network
|
|
|
| |
|
|
|
Eye Exam |
Paid in full |
$35 |
|
Lenses (per pair) |
|
|
| Single |
Paid in full |
$20 |
| Bifocal |
Paid in full |
$40 |
| Trifocal |
Paid in full |
$60 |
| Lenticular |
Paid in full |
$100 |
|
Contact Lenses |
|
|
| Elective (exam & lenses)** |
Exam plus $150 |
Exam plus $150 |
| Medically necessary* |
Paid in full |
$210 |
| Frame*** |
$50 wholesale |
$50 retail |
Polycarbonate lenses
(Adult and Children) |
Paid in full |
No benefit |
|
