Monthly Premiums
Retiree Only . . . . . . . . . . . . . . . . . . . . . . . . . . .$6.99
Retiree and Family . . . . . . . . . . . . . . . . . . . . . . .$15.88
Co-pays
Exam. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$20
Materials1 (not applicable to contact lenses). . . . . . .$15
Contact Lens Fitting . . . . . . . . . . . . . . . . . . . . . .$20
Co-pays apply to in-network benefits, co-pays for out-of-network visits are deducted
from reimbursements.
1 Materials co-pay applies to lenses or frames only, not contact lenses.
Services/Frequency
Exam. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Months
Frames . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Months
Contact Lens Fitting . . . . . . . . . . . . . . . . . . . . . .12 Months
Lenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Months
Contact Lenses . . . . . . . . . . . . . . . . . . . . . . . . .12 Months
Frequency is based on date of service.
Benefits
In-Network Out-of-Network
Exam (Ophthalmologist) . . . . . . . . . . . . Covered in full after $20 co-pay . . . . . . . .Up to $44 retail
Exam (Optometrist) . . . . . . . . . . . . . . . Covered in full after $20 co-pay . . . . . . . .Up to $39 retail
Frames . . . . . . . . . . . . . . . . . . . . . . . $130 retail allowance after $15 co-pay . . .Up to $63 retail
Contact Lens Fitting (Standard2) . . . . . . . Covered in full after $20 co-pay . . . . . . . .Not covered
Contact Lens Fitting (Specialty2) . . . . . . . $50 retail allowance after $20 co-pay . . . .Not covered
Lenses (Standard) Per Pair:
Single Vision . . . . . . . . . . . . . . . . . . Covered in full after $15 co-pay . . . . . . . .Up to $34 retail
Bifocal . . . . . . . . . . . . . . . . . . . . . . Covered in full after $15 co-pay . . . . . . . .Up to $48 retail
Trifocal . . . . . . . . . . . . . . . . . . . . . Covered in full after $15 co-pay . . . . . . . .Up to $64 retail
Standard Progressive lenses3 . . . . . . . Covered in full after $15 co-pay . . . . . . . .Up to $48 retail
Lenticular . . . . . . . . . . . . . . . . . . . . Covered in full after $15 co-pay . . . . . . . .Up to $88 retail
Factory Scratch Coat . . . . . . . . . . . . . Covered in full after $15 co-pay . . . . . . . .Not covered
Contact Lenses4 . . . . . . . . . . . . . . . . . . $120 retail allowance . . . . . . . . . . . . . . .Up to $100 retail
Medically Necessary Contact Lenses . . . . Covered in full . . . . . . . . . . . . . . . . . . .Up to $210 retail
All allowances are at a retail value; member is responsible for any amount over the allowance, minus available discounts.
2 Standard contact lens fitting applies to an existing contact lens user who wears disposable, daily wear, or extended wear lenses only. The
specialty contact lens fitting applies to new contact lens wearers and/or a member who wears toric, gas permeable, or multifocal lenses. For
the specialty fitting, the member is responsible for any charges over $50.
3 If premium progressive lenses are selected, members receive an allowance based on the provider’s charges for standard progressive lenses.
4 Contact lenses are in lieu of eyeglass lenses and frames benefit.
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