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| Vision Benefits | |||
|---|---|---|---|
| Service or Item | Basic Plan: Network | Enhanced Plan: Network | Both Plans: Non Network |
| Eye Exams: Subject to $50 Copayment | |||
| Eye exam, M.D. | Covered in full after copayment | Covered in full after copayment | Up to $38 |
| Eye exam, O.D. | Covered in full after copayment | Covered in full after copayment | Up to $38 |
| Eyeglasses: Subject to $25 materials Copayment | |||
| Frame | Up to $100 retail* | Up to $100 retail* | Up to $45 |
| Single vision lenses, pair | Covered in full after copayment | Covered in full after copayment | Up to $31 |
| Bifocal lenses, pair | Covered in full after copayment | Covered in full after copayment | Up to $51 |
| Trifocal lenses, pair | Covered in full after copayment | Covered in full after copayment | Up to $64 |
| Lenticular lenses, pair | Covered in full after copayment | Covered in full after copayment | Up to $80 |
| Progressive lenses, pair | Not covered | Covered up to $165* | Not covered |
| High index lenses, pair** | Not covered | Covered up to $116* | Not covered |
| Polycarbonate lenses, pair** | Not covered | Covered up to $116* | Not covered |
| Scratch coat | Not covered | Covered in full | Not covered |
| UV coat | Not covered | Covered in full | Not covered |
| Contact Lenses: Not subject to materials Copayment | |||
| When medically necessary | Covered in full | Covered in full | Up to $210 retail* |
| Elective/cosmetic retail | Up to $150 retail* | Up to $150 retail* | Up to $105 retail* |
| Contact Lens Exam (fitting fee) ($35 Copayment) | |||
| Specialty contacts*** | Not Covered | Up to $50* | Not Covered |
| Standard Contacts**** | Not Covered | Covered in full | Not Covered |
*You are responsible for any charges above the allowance.
** You may only be covered for one pair of high index lenses or polycarbonate lenses under the Enhanced Plan (up to the allowance provided above).
*** Specialty contacts are for new contact lens wearers or patients who wear toric, gas permeable or multi-focal lenses; includes two follow-up visits within three months of initial fitting.
**** Standard contacts are for existing contact lens wearers of disposable, daily wear or extended lenses; includes two follow-up visits within three months of initial fitting.
Notes:
Members can use either the contact lens benefit or the eyeglass benefit, but not both in the same plan year.
For non network claims, copayment amounts are deducted from the benefit allowance at the time of reimbursement.
Covered lenses are standard glass or plastic (CR-39), clear.