Services

In-network

Out-of-network

Exam (routine, non-medical)

Once per calendar year:
$15 co-pay

Once per calendar year:
Up to $35 reimbursement

Frames

Once per calendar year:

$0 co-pay, $175 allowance for any available frame, 20% off balance over $175

Once per calendar year:
Up to $88 reimbursement

Contact lenses

(in lieu of eyeglasses):

• Conventional

Once per calendar year:

$0 co-pay, 15% off balance over $175 allowance

Once per calendar year:

Up to $140 reimbursement

• Disposable

$0 co-pay, $175 allowance

Up to $140 reimbursement

• Medically necessary

$0 co-pay, paid in full

Up to $210 reimbursement

Standard plastic lenses:

• Single vision

$0 co-pay

Up to $25

• Bifocal

$0 co-pay

Up to $40

• Trifocal

Up to $55

• Lenticular

$0 co-pay

Up to $55

• Progressive – standard

$65 co-pay

Up to $40

• Progressive – Premium Tier 1

$85 co-pay

Up to $40

• Progressive – Premium Tier 2

$95 co-pay

Up to $40

• Progressive – Premium Tier 3

$110 co-pay

Up to $40

• Progressive – Premium Tier 4

$175 co-pay

Up to $40