Plan Information
Allowances are one-time use benefits; no remaining balance. Lost or broken materials are not covered.
Payment Schedule:
Vision Care Services
Member Cost In-Network
Out-of-network reimbursement
Exam with dilation as necessary
$10 copay
Up to $35
CONTACT LENS FITTING AND FOLLOW-UP (Available after a comprehensive eye exam is conducted)
Premium**
10% off retail price
N/A
Frames
$150 allowance; 20% off balance over $150
$50.00
Single Vision
$10 copay
Up to $25
Bifocal
$10 copay
Up to $40
Trifocal
$10 copay
Up to $55
Standard progressive lens
$75 copay
Up to $40
Premium progressive lens
$75 copay, 80% of charge less $120 allowance
Up to $40
LENS OPTIONS (paid by the member and added to the base price of the lenses)
Tint (solid and gradient)
$15
N/A
Standard plastic scratch coating
$15
N/A
Standard Polycarbonate
$40
N/A
Standard antireflective coating
$45
N/A
Other add-ons and services
20% off retail price
N/A
CONTACT LENSES (allowance covers materials only)
Conventional
$150 allowance; %15 off balance over $150
Up to $92
Disposables
$150 allowance; plus balance over $150
Up to $92
Medically necessary
$0 copay, paid in full
Up to $210
Lasik and PRK Vision Correction Procedures
15% off retail price OR 5% off promotional pricing
N/A
Exams
Once every 12 months
Frames
Once every 12 months
Standard plastic lenses
Once every 12 months
Contact lenses (in lieu of standard plastic lenses)
Once every 12 months
Exam with dilation as necessary
Member Cost In-Network: $10 copay
Out-of-Network Reimbursement: Up to $35
CONTACT LENS FITTING AND FOLLOW-UP (Available after a comprehensive eye exam is conducted)
Standard*
Member Cost In-Network: Up to $55
Out-of-Network Reimbursement: N/A
Premium**
Member Cost In-Network: 10% off retail price
Out-of-Network Reimbursement: N/A
Member Cost In-Network: $100 allowance; 20% off balance over $100
Out-of-Network Reimbursement: $50
Single Vision
Member Cost In-Network: $10 copay
Out-of-Network Reimbursement: $Up to $25
Bifocal
Member Cost In-Network: $10 copay
Out-of-Network Reimbursement: $Up to $40
Trifocal
Member Cost In-Network: $10 copay
Out-of-Network Reimbursement: $Up to $55
Standard progressive lens
Member Cost In-Network: $75
Out-of-Network Reimbursement: $Up to $40
Premium progressive lens
Member Cost In-Network: $75, 80% of charge less $120 allowance
Out-of-Network Reimbursement: $Up to $40
LENS OPTIONS (paid by the member and added to the base price of the lenses)
Tint (solid and gradient)
Member Cost In-Network: $15
Out-of-Network Reimbursement: N/A
UV Coating
Member Cost In-Network: $15
Out-of-Network Reimbursement: N/A
Standard plastic scratch coating
Member Cost In-Network: $15
Out-of-Network Reimbursement: N/A
Standard polycarbonate
Member Cost In-Network: $40
Out-of-Network Reimbursement: N/A
Standard antireflective
Member Cost In-Network: $45
Out-of-Network Reimbursement: N/A
Other add-ons and services
Member Cost In-Network: 20% discount
Out-of-Network Reimbursement: N/A
CONTACT LENSES (allowance covers materials only)
Conventional
Member Cost In-Network: $150 allowance; 15% off balance over $115
Out-of-Network Reimbursement: Up to $92
Disposables
Member Cost In-Network: $150 allowance; plus balance over $115
Out-of-Network Reimbursement: Up to $92
Medically necessary
Member Cost In-Network: $0 copay, paid in full
Out-of-Network Reimbursement: Up to $200
Lasik and PRK Vision Correction Procedures
Member Cost In-Network: 15% off retail price OR 5% off promotional pricing
Out-of-Network Reimbursement: N/A
Exams
Member Cost In-Network: Once every 12 months
Out-of-Network Reimbursement: N/A
Frames
Member Cost In-Network: Once every 12 months
Out-of-Network Reimbursement:N/A
Standard plastic lenses
Member Cost In-Network: Once every 12 months
Out-of-Network Reimbursement: N/A
Contact lenses (in lieu of standard plastic lenses)
Member Cost In-Network: Once every 12 months
Out-of-Network Reimbursement: N/A
*Standard contact lens fitting—spherical clear contact lenses in conventional wear and planned replacement (examples include but are not limited to disposable, frequent replacement, etc.)
**Premium contact lens fitting—all lens designs, materials, and specialty fittings other than standard contact lenses (toric, multifocal, etc.)