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Plan Frequencies |
Exam every 12 months
Lenses every 12 months
Frames every 12 months |
Copayment for each member at the time of service |
Exam: $15
Lenses and/or frames: $0 |
|
Maximum
Allowances |
Network Doctor
(After copayments/Up to plan limits) |
Non-network
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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 |
|
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Elective (fitting & lenses)** |
Exam + $130 |
Exam + $130 |
Medically necessary* |
Paid in full |
$210 |
Frame |
$45 wholesale |
$45 retail |
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