Overview of Coverage
Overview of Coverage
| BENEFIT | IN-NETWORK | OUT-OF-NETWORK REIMBURSEMENT 1 | |
|---|---|---|---|
| FREQUENCY | |||
| Eye examination (including dilation, as professionally indicated) | Once every calendar year | ||
| Eyeglass lenses | Once every calendar year under age 19/Once every two calendar years 19 or older | ||
| Frames | Once every two calendar years | ||
| Contact lenses (in lieu of eyeglass lenses) | Once every calendar year under age 19/Once every two calendar years 19 or older | ||
| EYE EXAMINATION | |||
| including dilation as professionally indicated | $20 copayment | Up to $40 allowance | |
| FRAMES | |||
| Fashion level frames from “The Collection” | Covered In Full | ||
| Designer level frames from “The Collection” | $20 copayment | ||
| Premier level frames from “The Collection” | $40 copayment | ||
| Retail allowance towards a provider’s frame | Up to $60 allowance | Up to $30 allowance | |
| STANDARD EYEGLASS LENSES 2 (per pair) | |||
| Single vision | Covered In Full | Up to $35 allowance | |
| Bifocal | Covered In Full | Up to $40 allowance | |
| Trifocal | Covered In Full | Up to $50 allowance | |
| Lenticular | Covered In Full | Up to $72 allowance | |
| OPTIONAL EYEGLASS LENSES (per pair) | Member Cost | ||
| Standard progressive lenses 3 | $50 discounted price | Not Covered | |
| Premium progressive lenses 3 | $90 discounted price | Not Covered | |
| Glass Grey #3 prescription sunglasses | $11 discounted price | Not Covered | |
| Polycarbonate lenses | |||
| Adult 4 | $30 discounted price | Not Covered | |
| Dependent Children | |||
| Single vision Polycarbonate lenses (in lieu of single vision lenses) | Covered In Full | Not Covered | |
| Bifocal Polycarbonate lenses (in lieu of bifocal lenses) | Covered In Full | Not Covered | |
| Trifocal Polycarbonate lenses (in lieu of trifocal lenses) | Covered In Full | Not Covered | |
| Blended segment lenses | $20 discounted price | Not Covered | |
| Intermediate vision lenses | $30 discounted price | Not Covered | |
| Glass photochromic lenses | $20 discounted price | Not Covered | |
| Plastic photosensitive lenses | $65 discounted price | Not Covered | |
| High-index (thinner and lighter) lenses | $55 discounted price | Not Covered | |
| Polarized lenses | $75 discounted price | Not Covered | |
| OPTIONAL EYEGLASS LENS COATINGS/TREATMENTS | Member Cost | ||
| Fashion, sun or gradient tinted plastic lenses | $11 discounted price | Not Covered | |
| Ultraviolet coating | $12 discounted price | Not Covered | |
| Scratch-resistant coating | $20 discounted price | Not Covered | |
| Standard ARC (anti-reflective coating) | $35 discounted price | Not Covered | |
| Premium ARC (anti-reflective coating) | $48 discounted price | Not Covered | |
| Ultra ARC (anti-reflective coating) | $60 discounted price | Not Covered | |
| CONTACT LENSES 5 (in lieu of eyeglass lenses – per pair or initial supply of disposable contact lenses) | |||
| Contact lens evaluation and fitting Daily Wear |
Covered in full when formulary contact lenses are prescribed | Not Covered | |
| Extended Wear | Covered in full when formulary contact lenses are prescribed | Not Covered | |
| Formulary 6 / Nonforumulary | |||
| Standard daily wear contact lenses | Covered In Full/ Up to $90 allowance 7 | Up to $90 allowance | |
| Specialty contact lenses | Covered In Full/ Up to $90 allowance 7 | Up to $90 allowance | |
| Disposable contact lenses | Covered In Full/ Up to $90 allowance 7 | Up to $90 allowance | |
| Medically necessary contact lenses (prior approval required) | Covered In Full |
Up to $225 allowance | |
| LOW VISION SERVICES | |||
| Evaluation – one visit every 5 years (prior approval required) | Up to $300 allowance per visit | ||
| Follow-up visits – up to four follow-up visits every 5 years | Up to $100 allowance per visit | ||
| Low vision aids | Up to $600 allowance per aid / $1,200 allowance lifetime maximum | ||
1 - If you choose an out-of-network provider, you must pay the provider directly for all charges and then submit a claim for reimbursement.
2 - Includes glass, plastic or oversized lenses.
3 - Progressive multifocals can be worn by most people. Conventional bifocals will be supplied at no additional charge for anyone who is unable to adapt to progressive lenses, however, the discounted price will not be refunded.
4 - Discounted member price waived for monocular patients and patients with prescriptions +/- 6.00 diopters or greater.
5 - Contact lenses can be worn by most people. Once the contact lens option is selected and the lenses fitted, they may not be exchanged for eyeglasses.
6 - Disposable contact lens wearers will receive four multi-packs of lenses. Planned replacement contact lens wearers will receive two multi-packs of lenses.
7 - Reimbursement amount is applied toward the cost of contact lenses. The allowance may or may not apply to the evaluation/fitting.
