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Monthly rates for: City of West Palm Beach
Effective date: January 1, 2004
| Employee: |
$0.00 |
| Employee + Family: |
$0.00 |
|
Rates show employee contribution only. |
| Plan Frequencies |
Exam 12 every months
Lenses12 every months
Frames 24 every months |
|
Copayment for each member at the time of service |
Exam
Lenses and/or frames |
$10
|
|
|
| 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 |
$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 |
$30 wholesale |
$30 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
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