Vision Benefits

Eye Exam

$10 Copay

Up to $35

Retinal Imaging

$39

Not Covered

Frames

$150 Allowance
20% off balance

Up to $75

Standard Plastic Lenses
Single Vision

Bifocal

Trifocal

Lenticular

$25 Copay

Up to $25

Up to $40

Up to $55

Up to $55

Lense Options:

Standard Polycarbonate

Adults: $40

Dependents Under 19: $0

Up to $25
Up to $25

UV Coating

$15

Not Covered

Tint (Solid and Gradient)

$15

Not Covered

Standard Scratch-Resistance

$15

Not Covered

Standard Anti-Reflective Coating

$45

Not Covered

Standard Progressive

$90 Copay

Up to $40

Premium Progressive

Tier 1 - $110 Copay

Tier 2 - $120 Copay

Tier 3 - $135 Copay

Tier 4 - $90 Copay
$120 Allowance &
20% off balance

Up to $40

Contact Lens Fit & Follow-Up
Standard

spherical clear contact lenses in conventional
wear and planned replacement (Examples
include but not limited to disposable, frequent

Premium

all lens designs, materials and specialty fittings
other than Standard Contact Lenses (Examples
include toric, multifocal, etc.)

$40 Copay
Paid-in-full and
2 follow-up visits

10% off balance

Not Covered

Not Covered

Contact Lenses
Conventional

Disposable

Medically Necessary

$150 Allowance

15% off balance

$150 Allowance

$0 Copay

Up to $90

Up to $90

Up to $200

Frequency
(Exams, Frames, Lenses or Contacts)

Once every Calendar Year

Once every Calendar Year

Employee

$4.18

Employee + Spouse

$8.78

Employee + Child(ren)

$7.53

Family

$14.08