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VISION CARE SERVICES
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IN-NETWORK |
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OUT-OF-NETWORK ALLOWANCES |
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Co-Pays
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Exam (Once per 12 months) |
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$15 |
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Up to $35 |
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Materials |
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$20 |
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See below |
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Standard Plastic Lenses
(Once per 12 months)
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Single Vision |
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Covered by Co-pay |
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Up to $25 |
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Bifocal |
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Covered by Co-pay |
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Up to $40 |
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Trifocal |
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Covered by Co-pay |
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Up to $50 |
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Lenticular |
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$80 Allowance |
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Up to $50 |
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Progressive |
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$70 Allowance |
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Up to $40 |
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Frames
(Once per 12 months)
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Choose any frame available at provider locations |
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$120 retail frame*
Covers a wide selection of frames
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Up to $50
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Contact Lenses
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(Once per 12 months)
(Includes fit, follow-up and materials) |
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$20 co-pay |
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In lieu of eyeglass lenses & frames |
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Up to $120 retail |
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Up to $100 retail allowance |
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Up to $210 retail |
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Up to $210 retail allowance |
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