In-Network |
In-Network |
Out-of-Network |
|
( Plus Providers) |
( Member Cost) |
( Reimbursement) |
|
Eye Exam— once every 12 months |
$ 0 copay |
$ 10 copay |
Up to $ 40 allowance |
Any available frame at providerlocation. |
$ 0copay: 20 % offbalance over $ 180 allowance |
$ 0copay; 20 % offbalance over $ 130 allowance |
Upto $ 91 allowance |
Lenses |
Single Vision Lenses |
$ 25 copay |
$ 25 copay |
Up to $ 30 allowance |
Bifocal Lenses |
$ 25 copay |
$ 25 copay |
Upto $ 50 allowance |
Trifocal Lenses |
$ 25 copay |
$ 25 copay |
Upto $ 70 allowance |
Lens Options UV Coating |
$ 15 |
$ 15 |
N / A |
Tint( Solid and Gradient) |
$ 15 |
$ 15 |
N / A |
Standard Plastic Scratch Coating |
$ 15 |
$ 15 |
N / A |
Standard Polycarbonate |
$ 40 |
$ 40 |
N / A |
Standard Anti-Reflective |
$ 45 |
$ 45 |
N / A |
Contacts |
Conventional |
$ 0copay: 15 % offbalance over $ 130 allowance |
$ 0copay; 15 % offbalance over $ 130 allowance |
Up to $ 130 allowance |
Disposable |
$ 0 copay: 100 % of balance over $ 130 allowance |
$ 0 copay; 100 % of balance over $ 130 allowance |
Up to $ 130 allowance |