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Vision Covered Services

Vision Plan Benefits

Benefit FrequencyStandard PlanEnhanced Plan
Participating ProviderNon-Participating ProviderParticipating ProviderNon-Participating Provider
Examination: Once Every 12 months1Covered 100%Reimbursement Amt:
Up to $40
Covered 100%
After $10 copay
Reimbursement Amt: Up to $40
Retinal ScreeningUp to $39 fixed pricing on a routine retinal screeningUp to $39 fixed pricing on a routine retinal screening
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)
Progressive Lenses (Tier 1)2$50 (fixed price) N/AN/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)220% discountN/A20% discountN/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)320% discountN/A20% discountN/A
$20-30 (fixed price)
N/ACovered 100%N/A
Photogrey$20-30 (fixed price)N/AN/A
Standard Transitions$65-70 (fixed price)N/AN/A
Standard Scratch Coating$10 (fixed price)N/AN/A
UV CoatingCovered 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 MonthsRetail Allowance Up to $200
(20% discount off balance)4
Up to $50Retail Allowance Up to $250
(20% discount off balance)4
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
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 Aids7: Once Every 2 YearsUp to $999N/AUp to $999N/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.

National Vision AdministratorsVision 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.

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