Vision Benefits

Exam

$10 Copay

Up to $45 Allowance

Lenses

Single

$10 Copay

Up to $30 Allowance

Lined Bifocal

$10 Copay

Up to $50 Allowance

Lined Trifocal

$10 Copay

Up to $65 Allowance

Lenticular

$10 Copay

Up to $100 Allowance

Frames

$130 Allowance + 20% off
amount over Allowance

Up to $70 Allowance

Contact Lenses

Elective

$130 Allowance

Up to $105 Allowance

Medically Necessary

$10 Copay

Up to $210 Allowance

Exam

1 per 12 months

Lenses

1 pair per 12 months

Frames

1 set per 24 months

Contacts

1 per 12 months (instead of lens and frames)

Employee

$6.82

Employee + Spouse

$13.68

Employee + Child(ren)

$11.60

Family

$19.10