Page 35 - 2022 Washington Nationals Flipbook

WASHINGTON NATIONALS BASEBALL CLUB, LLC

Eye Care Highlight Sheet

Plan 1: Balanced Care Vision I Plan Summary

VSP Choice Network Out of Network

Deductibles $10 Exam
$25 Eye Glass Lenses or Frames
$10 Exam
Up to $45
$25 Eye Glass Lenses or Frames*
Up to $30
Annual Eye Exam Covered in full Up to $50
Up to $65
Lenses (per pair) Up to $100

Single Vision Covered in full NA

Bifocal Covered in full No benefit

Trifocal Covered in full Up to $105
Up to $210
Lenticular Covered in full Up to $70

Progressive See lens options 12/12/24
Based on date of service
Contacts
Out of Network
Fit & Follow Up Exams Participant cost up to $60 Up to Lined Bifocal allowance.

Elective Up to $130 No benefit

Medically Necessary Covered in full No benefit

Frames $130 No benefit
No benefit
Frequencies (months)
No benefit
Exam/Lens/Frame 12/12/24 No benefit
No benefit
Based on date of service

*Deductible applies to a complete pair of glasses or to frames, whichever is selected.

Lens Options (participant cost)*

Progressive Lenses VSP Choice Network
Up to provider’s contracted fee for Lined

Bifocal Lenses. The patient is responsible

for the difference between the base lens and

the Progressive Lens charge.

Std. Polycarbonate Covered in full for dependent children
$33 adults

Solid Plastic Dye $15
(except Pink I & II)

Plastic Gradient Dye $17

Photochromatic Lenses $31-$82

(Glass & Plastic)

Scratch Resistant Coating $17-$33

Anti-Reflective Coating $43-$85

Ultraviolet Coating $16

*Lens Option participant costs vary by prescription, option chosen and retail locations.

Standard Insurance Company
Benefit and Cost Summary Highlight Sheet