IN NETWORK | OUT OF NETWORK | |
---|---|---|
Covered Services Every 12 Months | ||
Annual Exam | 100%, no copay | $40 allowance |
Frames | $130 allowance; 20% discount | $45 allowance |
Lenses* | ||
Single Vision | 100% after $35 copay | $25 allowance |
Bifocal | 100% after $35 copay | $40 allowance |
Trifocal | 100% after $35 copay | $55 allowance |
Lenticular | 100% after $35 copay | $75 allowance |
Contacts | ||
Elective Conventional | $200 allowance; 15% discount | $105 allowance |
Elective Disposable | $200 allowance | $105 allowance |
Non-Elective | 100% | $210 allowance |
Contact Lens Fitting | 100% | Not covered |