|
 |


Plan Frequencies |
Exam every 12 months
Lenses every 12 months
Frames every 12 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 |
$30 |
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 and lenses)** |
Exam +
$125 |
Exam +
$125 |
Medically necessary* |
Paid in full |
$150 |
Frame |
$50 wholesale |
$50 retail |
|