Table
of Covered Vision Care
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Eye
Examinations
Benefits are provided once
each calendar year for a complete analysis of the eyes and related structure to
determine the presence of vision problems or other abnormalities. This exam must
include refraction and must be performed by a licensed ophthalmologist (MD or
DO) or optometrist (OD).
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$ 80
(changed effective 3/1/2007) |
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Prescription
Lenses
Benefits are provided once
each calendar year for one pair
of lenses to improve visual acuity.
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Single vision
Bifocal
Progressive
Trifocal
Lenticular |
$ 65
$ 95
$135
$135
$150 |
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Contact
Lenses
Benefits are provided once
each calendar year for one pair of contact lenses when purchased in place of
conventional lenses and frames. Benefits for disposable and/or replacement
contact lenses are covered within the same annual maximum.
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$125
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Special Lens
Treatment
Benefits are provided once
each calendar year for certain features when such services are provided at an
extra charge. These features include anti-reflective coating, tinting, oversized
lenses, and scratch coating.
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$ 20
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Frames
Benefits are provided once
each calendar year for frames.
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$ 80 |
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