 |
 |
 |
|
||
|
|
|||
|
 |
|
|
VisionCare Plan Overview VisionCare Plan offers you and your family a benefit that covers all routine eye care, including eye exams and eyeglasses (lenses and frames) or contacts. The plan features:
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Plan Frequencies |
Exam every 12 months Lenses every 12 months Frames every 24 months |
| Copayment for each member at the time of service |
| Exam $10.00 |
| Lenses and/or frames $15.00 |
| Maximum Allowances | Network Doctor Non-network (After copayments/Up to plan limits) |
Non-network (copayments apply) |
| 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) ** | $105 | $105 |
| Medically necessary* | Paid in full | $150 |
| Frame | $45 wholesale | $45 retail |
| LASIK*** | We have contracted with many of the finest LASIK facilities and eye doctors to offer this procedure at substantially reduced fees. The network of LASIK centers features all TLC Laser Center (TLC Vision) facilities as well as many of the leading independent centers in the country | |
| Discount Only | No benefit | |
*Medically necessary (prior authorization required) is
defined as 1) following cataract surgery w/o intraocular lens; 2)
correction of extreme visual acuity problems not correctable with
glasses; 3) anisometropia greater than 5.00 diopters and asthenopia
or diplopia, with spectacles; 4) Keratoconus; or 5) monocular aphakia
and/or binocular aphakia where the doctor certifies contact lenses
are medically necessary for safety and rehabilitation to a
productive life.
**We will cover the combined cost of an annual vision exam, contact lens
evaluation exam, fitting cost and contact lenses up to a maximum of $125.
Payment will be in lieu of all other benefits. The copayment is waived.
This schedule shows only a few of the covered
procedures. Please see your Benefit Administrator for a complete schedule.
This schedule is intended for comparison purposes only. The benefits of
each plan will be determined by the contract. For a complete listing of
benefits and exclusions and limitations, please reference your certificate
of coverage. This schedule shows only a few of the covered
procedures. Please see your Benefit Administrator for a complete schedule.
This schedule is intended for comparison purposes only. The benefits of
each plan will be determined by the contract. For a complete listing of
benefits and exclusions and limitations, please reference your certificate
of coverage.
***Plan members must first contact CompBenefits for a list of providers and to receive a Refractive Care ID card.
To submit comments or questions, please visit our Contact Center. © Copyright CompBenefits 2005.
|