Page 22 - 2022 The Reserve at Arlington Benefit Guide

Vision Option:

Mutual of Omaha

26 Pay Period Rate Information
Dependent Information

Employee Only $3.09 We offer our employees the opportunity to cover their
spouse or dependent children. Children can join or re-
Employee + Spouse $5.79
main on a parent’s vision plan until age 26. When a
Employee + Child(ren) $6.82 child turns 26, they will lose vision coverage on the last
day of their birth month. This is an automated process.
Employee + Family $9.55

Benefits (In-Network) Plan Coverage

Copays:

Exam $10 Copay
Materials (Lens and Frames) $25 Copay
Standard Contact Fit & Follow Up Up to $40 Copay
Frequency: (Based on Date of Service)

Exams Every 12 Months
Lenses Every 12 Months
Frames Every 24 Months
Contact Lenses Every 12 Months
Standard Plastic Lenses:
Single Vision $25 Copay

Lined Bifocal $25 Copay
Lined Trifocal $25 Copay
Progressive Lenses $65 Copay added to Bifocal Copay
Scratch Resistant Coating $0 Copay
UV Treatment $0 Copay
Tint $0 Copay
Frames:

Frames Allowance / $0 Copay $130 allowance, plus 20% off Balance over
Additional Pairs of Glasses Up to 40% Discount
Contact Lenses in lieu of eye glasses, materials only:

Frequency Every 12 Months
Fitting and Evaluation Allowance See Above
Lens Allowance / $0 Copay $130 allowance, plus 15% off Balance over

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