Page 91 - 2023 Down East Wood Ducks - Benefits Guide.docx_Neat

APPENDIX V-2

[Minor League Front Office Plan] High Option

Benefits include coverage for one comprehensive eye exam, contact lens evaluation and fitting, and one
pair of glasses (or contact lenses, in lieu of glasses) per year, as described in the benefits booklet.
Benefits also include discounted prices for certain lenses, lens coatings and treatments. Single-vision
spectacle, lined bifocal, trifocal, oversize, and lenticular lenses with scratch-resistant coating are all
covered in full when provided in-network. You may visit any vision provider of your choosing, but note
that you receive the greatest value and maximize your benefit dollars if you select a network provider. If
you choose an out-of-network provider, you must pay the provider directly for all charges and then
submit a claim for reimbursement. The reimbursement amounts for out-of-network providers are
described in the benefits booklet. While you may “split” your benefits by receiving your eye examination
and eyeglasses (or contact lenses) on different dates or through different providers, complete eyeglasses
must be obtained at one time and from one provider (in- or out-of-network).
This program also contains a laser vision correction services discount program, which includes LASIK.
Services must be rendered by a network professional provider who has specifically contracted with
Highmark to provide such services. You are responsible for paying the entire discounted price to the
provider.

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