Vision

Quick Reference

Active eligible members, spouses and dependent children up to age 26: services once per plan year (October 1 – September 30)

	In-Network
Exam	Plan pays 100%
Eyeglasses (lenses and frames or contacts)	Plan pays 100% (up to $200 allowance for frames) Copayments apply for premium frames, anti-reflective coating and other features such as photosensitive lenses, high-index lenses, scratch-resistant coatings and polarized lenses
Laser Vision Correction Surgery (LASIK)	15% off retail or 5% off promotional price

	Out-of-Network
Eyeglasses (lenses and frames)	Exam: $40 allowance Frames: $140 allowance Single Lenses: $30 allowance Bifocal Lenses: $50 allowance Contact Lenses: $140 allowance