Vision Plan Benefits
| 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 |
1 Some optometrist affiliated with Optical Retail locations (i.e., Costco, Walmart, Visionworks, etc.) are independent providers and may not participate in the NVA program.
2 Progressive Lenses — Multifocal lenses with no lines. There is not a harsh jump in focus that bifocal and trifocal wearers experience because the change is gradual.
3 Anti-Reflective Coating — Specific coatings designed to decrease the amount of reflective light in your lenses.
4 Discount does not apply at Walmart, Sam’s Club or Costco locations or certain proprietary brands or where prohibited by law. Discounts are not insured benefits.
5 Discount does not apply at Walmart or Sam’s Club or Costco locations or Contact Fill.
6 Fittings vary at Walmart/Sam’s Club locations and are only covered if you choose Contact Lenses.
7 Prior authorization required from NVA.
Note: Members pay the lower of the fixed price or 20% off the provider’s usual and customary price. Fixed prices are available in-network only. Members receive a 20% courtesy discount on lens options not listed above. Fixed prices/courtesy discount do not apply at Costco, Walmart/Sam’s Club locations. In certain states, members may be required to pay the full retail amount and not the negotiated discount amount at certain participating providers.
FOR COMPARISON USE ONLY. This comparison is only a brief summary of benefits offered under each plan. Complete details, including limitations and exclusions, are detailed in the policy. In the event of discrepancies, the policy shall govern.
Vision insurance coverage is provided by National Vision Administrators® (NVA). Since 1979, NVA has built a quality reputation for Vision Insurance featuring great customer support and a strong nationwide network of providers that give unparalleled service to its customers. 
