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| This plan
is designed for broader network accessibility and affordability. For ease
of understanding, 10-70 is a plan with a $10 exam co-pay and $70 frame
and contact lens allowance. This plan uses not only the Standard Optical
Network but also over 40 independent Optometrist who are credentialed on
our Expanded panel. |
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Select Network |
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Broad Network |
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Out-of-
Network |
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| Eye Exam |
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| Eyeglass Exam |
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$10 Copay |
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$20 Copay |
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$40 Allowance |
| Contact Exam |
$10 Copay |
$20 Copay |
$40 Allowance |
| Dilation |
100% Covered |
Retail |
Included Above |
| Contact Fitting |
100% Covered |
Retail |
Included Above |
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| Lenses *Standard Plastic |
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| Single Vision |
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100% Covered |
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$20 Copay |
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$75 Allowance for lenses, options, and coatings |
| Bifocal (FT 28) |
100% Covered |
$20 Copay |
| Trifocal (FT 7x28) |
100% Covered |
$20 Copay |
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| Lens Options |
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| Progressive (Standard plastic no-line*) |
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$50 Co-pay |
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$75 Co-pay |
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| Glass lenses |
15% Discount |
15% Discount |
| Polycarbonate |
$40 Co-pay |
25% Discount |
| High Index |
$80 Co-pay |
25% Discount |
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| Coatings |
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| Scratch Resistant Coating |
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100% Covered |
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$10 Copay |
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| Ultra Violet protection |
100% Covered |
$10 Copay |
| Other Options - A/R, edge polish, tints, mirrors, etc. |
25% Discount |
25% Discount |
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| Frames |
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| Allowance Based on Retail Pricing |
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$70 Allowance |
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$60 Allowance |
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$50 Allowance |
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| Additional pairs of glasses throughout the year |
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50% off Retail |
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25% off Retail |
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| Contacts |
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$70 Allowance |
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$50 Allowance |
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$50 Allowance |
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Contact benefit is in lieu of lens and frame benefit |
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| Additional Contact Purchases |
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| Conventional |
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Up to 20% off |
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Retail |
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| Disposables |
Up to 10% off |
Retail |
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| Refractive surgery (LASIK) |
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$100.00 off per eye |
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LASIK services are not an insured benefit - this is a discount only
Surgery through Physicians Laser Center of SLC, UT
All pre & post operative care provided by Standard Optical
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| Discounts |
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Any item listed as a discount in the benefit outline above is a merchandise discount only and not an insured benefit |
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