Vision Benefits

Exam and Materials - Employee Pays 100%

Exam with Dilation as Necessary

$10 Copay

$30

Retinal Imaging Benefit

Up to $39

N/A

Exam Options

Standard Contact Lens Fit and Follow-Up:

Up to $40

N/A

Premium Contact Lens Fit and Follow-Up:

10% off Retail

N/A

Frames

Any available frame at provider location

$0 Copay $130 Allowance
20% off balance over
$130

$65

Standard Plastic Lenses

Single Vision

$25 Copay

$25

Bifocal

$25 Copay

$40

Trifocal

$25 Copay

$60

Lenticular

$25 Copay

$60

Standard Progressive Lens**

$90

$40

Premium Progressive Lens**

$90, 80% of Charge less $120 Allowance

$40

Lens Options:

UV Treatment

$15

N/A

Tint (Solid and Gradient)

$15

N/A

Standard Plastic Scratch Coating

$15

N/A

Standard Polycarbonate – Adults

$40

N/A

Standard Polycarbonate – Kids under 19

$40

N/A

Standard Anti-Reflective Coating

$45

N/A

Polarized

20% off Retail Price

N/A

Other Add-Ons

20% off Retail Price

N/A

Contact Lenses
(Contact lens allowance includes materials only)

Conventional

$0 Copay $130 allowance
15% off balance over
$130

$104

Disposable

$0 Copay $130 allowance, plus balance over
$130

$104

Medically Necessary

$0 Copay, Paid in Full

$200

Lasik or PRK from U.S. Laser Network

15% off retail price or 5% off promotional price

N/A

Additional Pairs Benefit

Members also receive a 40% discount off
complete pair eyeglass purchases and a 15%
discount off conventional contact lenses once
the funded benefit has been used.

N/A

Frequency

Examination

Once every 12 months

Lenses or Contact Lenses

Once every 12 months

Frame

Once every 24 months

Employee

$6.21

Employee + Spouse

$11.80

Employee + Child(ren)

$12.42

Family

$18.26

Frames

Any available frame at provider location

$0 copay; 20% off balance over $130 allowance

Up to $65

Standard Plastic Lenses

Single Vision

$0 Copay

Up to $25

Bifocal

$0 Copay

Up to $40

Trifocal

$0 Copay

Up to $60

Lenticular

$0 Copay

Up to $60

Standard Progressive Lens

$65 Copay

Up to $40

Premium Progressive Lens Tier 1-4

$65 copay; 20% off retail price less $120 allowance

Up to $40

Lens Options

Anti Reflective Coating - Standard

$45

Not covered

Anti Reflective Coating - Premium Tier 1 - 4

20% off retail price

Not covered

Polycarbonate - Standard

$40

Not covered

Scratch Coating - Standard Plastic

$15

Not covered

Tint - Solid and Gradient

$15

Not covered

UV Treatment

$15

Not covered

All Other Lens Options

20% off retail price

Not covered

Contact Lenses

Conventional

$0 copay; 15% off balance over $130 allowance

Up to $104

Disposable

$0 copay; 100% of balance over $130 allowance

Up to $104

Medically Necessary

$0 Copay

Up to $200

Other

Hearing Care from Amplifon Network

Up to 66% off hearing aids; call 1-877-203-0675

Not covered

Exam Services

LASIK or PRK from U.S. Laser Network

15% off retail or 5% off promo price; call
1.800.988.4221

Not covered

Plan allows the member to receive either contacts and frame, or frame and lens services.

Lenses

Once every 12 months from the date of service

Once every 12 months from the date of service

Frame

Once every 24 months from the date of service

Once every 24 months from the date of service

Contact Lenses

Once every 12 months from the date of service

Once every 12 months from the date of service

Employee Only

$6.38

Employee + Spouse

$12.10

Employee + Children

$12.74

Family

$18.74