Vision

Services	In-Network	Out-of-Network
Exams	$10 Copay	Up to $40 reimbursement
Eyeglass Lenses • Single Vision Lenses • Bifocal Lenses • Trifocal Lenses • Lenticular Lenses	100% after $25 Copay 100% after $25 Copay 100% after $25 Copay 100% after $25 Copay	Up to $40 reimbursement Up to $60 reimbursement Up to $80 reimbursement Up to $80 reimbursement
Frames	$130 allowance, then 30% discount on remaining balance	Up to $45 reimbursement
Contact Lenses • Elective Contact Lenses • Medically Necessary	$130 allowance 100% after $25 Copay	Up to $105 reimbursement Up to $210 reimbursement
	Service Frequencies
Exams Lenses Frames Contacts	Once Every 12 Months Once Every 12 Months Once Every 24 Months Once Every 12 Months