 |
|
|
|
|
|
|
|
|
|
Select Network |
|
Broad Network |
|
Out-of-
Network |
|
| Eye Exam |
|
| Eyeglass Exam |
|
No Eye Examination Benefit |
|
|
|
| Lenses *Standard Plastic |
|
| Single Vision |
|
100% Covered |
|
$20 Copay |
|
$75 Allowance for lenses, options, and coatings |
| Bifocal (FT 28) |
100% Covered |
$20 Copay |
| Trifocal (FT 7x28) |
100% Covered |
$20 Copay |
|
|
|
|
|
| Lens Options |
|
| Progressive (Standard plastic no-line*) |
|
$50 Co-pay |
|
$75 Co-pay |
|
|
| Glass lenses |
15% Discount |
15% Discount |
| Polycarbonate |
$40 Co-pay |
25% Discount |
| High Index |
$80 Co-pay |
25% Discount |
|
|
|
|
|
| Coatings |
|
| Scratch Resistant Coating |
|
100% Covered |
|
$10 Copay |
|
|
| Ultra Violet protection |
100% Covered |
$10 Copay |
| Other Options - A/R, edge polish, tints, mirrors, etc. |
25% Discount |
25% Discount |
|
|
|
|
|
| Frames |
|
| Allowance Based on Retail Pricing |
|
$70 Allowance |
|
$60 Allowance |
|
$50 Allowance |
|
|
|
|
|
| Additional pairs of glasses throughout the year |
|
|
|
50% off Retail |
|
25% off Retail |
|
|
|
|
|
|
|
| Contacts |
|
|
|
$70 Allowance |
|
$50 Allowance |
|
$50 Allowance |
|
|
|
Contact benefit is in lieu of lens and frame benefit |
|
| Additional Contact Purchases |
|
| Conventional |
|
Up to 20% off |
|
Retail |
|
|
| Disposables |
Up to 10% off |
Retail |
|
|
|
|
