| IN NETWORK | OUT OF NETWORK | |
|---|---|---|
| Covered Services Every 12 Months | ||
| Annual Exam | 100%; no copay | $40 allowance |
| Frames | $200 allowance; 20% discount | $45 allowance |
| Lenses* | ||
| Single Vision | $20 copay | $25 allowance |
| Bifocal | $20 copay | $40 allowance |
| Trifocal | $20 copay | $55 allowance |
| Lenticular | $20 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 |