Vision PPO Plan Summary

Vision PPO Option 1
  In-Network Out-of-Network
Annual Eye Exam $10 copay Up to $42
Fit and Follow-up Exams Covered in full Up to $40
Frames $130 allowance, 20% off amount over allowance Up to $65
Lenses    
Single $10 copay Up to $35
Bifocal $10 copay Up to $40
Trifocal $10 copay Up to $65
Progressive $75 copay Up to $40
Premium Progressive $75 copay,
$120 allowance, 20% off amount over allowance
Up to $40
Contacts    
Elective - Conventional $130 allowance, 15% off amount over allowance Up to $104
Elective - Disposable $130 allowance Up to $104
Medically Necessary Covered in full Up to $200
Lens Options    
UV Coating $15 copay No benefit
Tint - Solid and gradient $15 copay No benefit
Scratch-resistant $15 copay No benefit
Polycarbonate $40 copay No benefit
Anti-reflective $45 copay No benefit
Other add-ons and services 20% off amount No benefit
Frequencies in Months Lenses or contacts 12 Frames 12 or 24 Lenses or contacts 12 Frames 12 or 24
Vision PPO Option 2
  In-Network Out-of-Network
Annual Eye Exam $10 copay Up to $42
Fit and Follow-up Exams Up to $55 copay No benefit
Frames $130 allowance, 20% off amount over allowance Up to $65
Lenses    
Single $25 copay Up to $35
Bifocal $25 copay Up to $40
Trifocal $25 copay Up to $65
Progressive $90 copay Up to $40
Premium Progressive $90 copay,
$120 allowance, 20% off amount over allowance
Up to $40
Contacts    
Elective - Conventional $130 allowance, 15% off amount over allowance Up to $104
Elective - Disposable $130 allowance Up to $104
Medically Necessary Covered in full Up to $200
Lens Options    
UV Coating $15 copay No benefit
Tint - Solid and gradient $15 copay No benefit
Scratch-resistant $15 copay No benefit
Polycarbonate $40 copay No benefit
Anti-reflective $45 copay No benefit
Other add-ons and services 20% off amount No benefit
Frequencies in Months Lenses or contacts 12 Frames 12 or 24 Lenses or contacts 12 Frames 12 or 24
Vision PPO Option 3
  In-Network Out-of-Network
Annual Eye Exam $10 copay Up to $42
Fit and Follow-up Exams Up to $55 copay No benefit
Frames $100 allowance, 20% off amount over allowance Up to $50
Lenses    
Single $25 copay Up to $35
Bifocal $25 copay Up to $40
Trifocal $25 copay Up to $65
Progressive $90 copay Up to $40
Premium Progressive $90 copay,
$120 allowance, 20% off amount over allowance
Up to $40
Contacts    
Elective - Conventional $115 allowance, 15% off amount over allowance Up to $92
Elective - Disposable $115 allowance Up to $92
Medically Necessary Covered in full Up to $200
Lens Options    
UV Coating $15 copay No benefit
Tint - Solid and gradient $15 copay No benefit
Scratch-resistant $15 copay No benefit
Polycarbonate $40 copay No benefit
Anti-reflective $45 copay No benefit
Other add-ons and services 20% off amount No benefit
Frequencies in Months Lenses or contacts 12 Frames 12 or 24 Lenses or contacts 12 Frames 12 or 24