Securing Your Financial Future –
Entrusted since 1957

Securing Your Financial Future – Entrusted since 1957

Vision Insurance: Covered Services

Benefit FrequencyStandard PlanEnhanced Plan
Participating ProviderNon-Participating ProviderParticipating ProviderNon-Participating Provider
Examination: Once Every 12 monthsCovered 100%Reimbursement Amt:
Up to $40
Covered 100%
After $10 copay
Reimbursement Amt: Up to $40
Lenses: Once every 12 monthsStandard Glass or PlasticStandard Glass or Plastic
Single VisionCovered 100%Up to $30Covered 100%Up to $30
BifocalUp to $40Up to $40
TrifocalUp to $75Up to $75
LenticularUp to $75Up to $75
Solid TintsN/AN/A
Fashion Gradient TintsN/AN/A
Blended Bifocal (Segment)N/AN/A
Polycarbonates100% up to age 19

$25-$30 (fixed price for age 19 and over)
N/AN/A
Standard Progressive Lenses1$50 (fixed price) N/AN/A
Premium Progressive Lenses2$100 (fixed price)N/A$100 (fixed price)N/A
PhotochromaticN/A
$20-30 (fixed price)
N/ACovered 100%N/A
PhotogreyN/AN/A
Standard Transitions$65-70 (fixed price)N/AN/A
Standard Scratch Coating$10 (fixed price)N/AN/A
Frame: Once Every 12 MonthsRetail Allowance Up to $150
(20% discount off balance)3
Up to $50Retail Allowance Up to $150
(20% discount off balance)3
Up to $30
Contact Lenses: Once Every 12 monthsIn Lieu of GlassesIn Lieu of Lenses
Elective Contact LensesUp to $150 Retail
15% (Conventional) or 10%
(Disposable) off balance4
Up to $130Up to $150 Retail
15% (Conventional) or 10%
(Disposable) off balance4
Up to $130
Contact Lens
Evaluation/Fitting5
Covered 100%
after $20 Daily Wear
$30 Extended Wear
$50 Specialty Wear copay
Daily Wear: up to $20
Extended Wear: up to $30
Specialty Wear: up to $50
Covered 100%
after $20 Daily Wear
$30 Extended Wear
$50 Specialty Wear copay
Daily Wear: up to $20

Extended Wear: up to $30

Specialty Wear: up to $50
Medically Necessary6Covered 100%Up to $260Covered 100%Up to $260
Low Vision Aids6: Once Every 2 YearsUp to $999N/AUp to $999N/A

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