EYEGLASSES
$15 co-pay applies |
|
| Materials |
Participating Coverage Allowance |
|
*Lenses, one pair per 12 months
Single vision lenses
Lined bifocal lenses
Lined trifocal lenses
Progressive Addition lenses
**Frames, one pair per 24 months |
Pays 100%
Pays up to cost of lined trifocal lenses
Pays 100% up to Plan Allowance |
*Optional lens enhancements which exceed the Plan Limit and which may be purchased by the patient include: tinted, high index, ultraviolet coating or scratch coating.
**Price of frames varies by provider. Plan Limit frame price is typically between $90.00 and $120.00.
Patient may pay the difference in cost for a frame which exceeds the Plan Limit.
|
CONTACT LENSES
No co-pay required |
|
| Materials |
Participating Coverage Allowance |
|
Once per 12 months in lieu
of lenses and/or frames.
All types of contact lenses are covered including disposable, rigid, gas permeable and soft.
|
|
Visually necessary
Medically necessary
(for Keratoconus and Aphakia) |
$105
$165
|
|
Fee for contact lens fitting is not considered part of the routine well-eye exam. Fee can be considered as part of the contact lens allowable if a benefit remains after contact lenses are purchased.
|
COSMETIC SURGERY AND COSMETIC WRINKLE REMOVAL |
|
| Service |
Participating Coverage Allowance |
|
Cosmetic Eye Surgery
Cosmetic Wrinkle Removal
|
20% Discount
20% Discount
|
