Page 9 - Drive DeVilbiss - 2022 Union Guide

Vision plan

The vision plan provides coverage for routine eye exams and pays for all or a portion of the cost of glasses or contact
lenses. You can choose any provider; however, you always save money if you see in-network providers. We offer vision
through Empire. To locate an Empire provider refer to www.empireblue.com and search using the “Blue View Vision” network.

Vision PPO
Plan Provisions In-Network Out-of-Network

Exam $10 copay Up to $42

$150 allowance plus 20%
Frames Up to $45
discount off balance
Frequency
● Exam ● 12 months

● Lenses or Contacts ● 24 months

● Frames ● 24 months

Lenses
● Single vision lenses ● Up to $40

$10
● Bifocal lenses ● Up to $60

● Trifocal lenses ● Up to $80
Contact Lenses
$150 allowance plus 15%
● Elective in lieu of Up to $105
discount off balance
glasses

9