Vision Insurance: Covered Services
| Benefit Frequency | Standard Plan | Enhanced Plan | ||
|---|---|---|---|---|
| Participating Provider | Non-Participating Provider | Participating Provider | Non-Participating Provider | |
| Examination: Once Every 12 months1 | Covered 100% | Reimbursement Amt: Up to $40 | Covered 100% After $10 copay | Reimbursement Amt: Up to $40 |
| Retinal Screening | Up to $39 fixed pricing on a routine retinal screening | Up to $39 fixed pricing on a routine retinal screening | ||
| Lenses: Once every 12 months | Standard Glass or Plastic | Standard Glass or Plastic | ||
| Single Vision | Covered 100% | Up to $30 | Covered 100% | Up to $30 |
| Bifocal | Up to $40 | Up to $40 | ||
| Trifocal | Up to $75 | Up to $75 | ||
| Lenticular | Up to $75 | Up to $75 | ||
| Solid Tints | N/A | N/A | ||
| Fashion Gradient Tints | N/A | N/A | ||
| Blended Bifocal (Segment) | N/A | N/A | ||
| Polycarbonates | 100% up to age 19 $25-$30 (fixed price for age 19 and over) | N/A | N/A | |
| Progressive Lenses (Tier 1)2 | $50 (fixed price) | N/A | N/A | |
| Progressive Lenses (Tier 2)2 | $80 (fixed price) | N/A | $80 (fixed price) | N/A |
| Progressive Lenses (Tier 3)2 | $100 (fixed price) | N/A | $100 (fixed price) | N/A |
| Progressive Lenses (Tier 4)2 | $120 (fixed price) | N/A | $120 (fixed price) | N/A |
| Progressive Lenses (Tier 5)2 | $140 (fixed price) | N/A | $140 (fixed price) | N/A |
| Progressive Lenses (Tier 6)2 | $165 (fixed price) | N/A | $165 (fixed price) | N/A |
| Progressive Lenses (Tier 7)2 | $190 (fixed price) | N/A | $190 (fixed price) | N/A |
| Progressive Lenses (Tier 8)2 | 20% discount | N/A | 20% discount | N/A |
| Anti-Reflective Coating (Tier 1)3 | $40 (fixed price) | N/A | $40 (fixed price) | N/A |
| Anti-Reflective Coating (Tier 2)3 | $50 (fixed price) | N/A | $50 (fixed price) | N/A |
| Anti-Reflective Coating (Tier 3)3 | $65 (fixed price) | N/A | $65 (fixed price) | N/A |
| Anti-Reflective Coating (Tier 4)3 | $80 (fixed price) | N/A | $80 (fixed price) | N/A |
| Anti-Reflective Coating (Tier 5)3 | 20% discount | N/A | 20% discount | N/A |
| Photochromatic | N/A $20-30 (fixed price) | N/A | Covered 100% | N/A |
| Photogrey | $20-30 (fixed price) | N/A | N/A | |
| Standard Transitions | $65-70 (fixed price) | N/A | N/A | |
| Standard Scratch Coating | $10 (fixed price) | N/A | N/A | |
| UV Coating | Covered 100% | N/A | $12 (fixed price) | N/A |
| Blue Light Blocker | $40-$150 (fixed price) | N/A | $40-$150 (fixed price) | N/A |
| Polorized | $75 (fixed priced) | N/A | $75 (fixed priced) | N/A |
| High Index | $55 (fixed priced) | N/A | $55 (fixed priced) | N/A |
| Frame: Once Every 12 Months | Retail Allowance Up to $200 (20% discount off balance)4 | Up to $50 | Retail Allowance Up to $250 (20% discount off balance)4 | Up to $30 |
| Contact Lenses: Once Every 12 months | In Lieu of Glasses | In Lieu of Lenses | ||
| Elective Contact Lenses | Up to $150 Retail 15% (Conventional) or 10% (Disposable) off balance4 | Up to $130 | Up 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 Necessary6 | Covered 100% | Up to $260 | Covered 100% | Up to $260 |
| Low Vision Aids7: Once Every 2 Years | Up to $999 | N/A | Up to $999 | N/A |
