Page 13 - 2024 ANS Benefit Guide - 2-1-24 Employee Navigator

Vision Option:

BCBS of Oklahoma

PAY PERIOD 24 26
Dependent Information
Employee Only No Cost No Cost
Our company offers our employees the opportunity to
Employee + Spouse No Cost No Cost
cover their spouse or dependent children. Children can
join or remain on a parent’s vision plan until age 26.
Employee + Child(ren) No Cost No Cost
When a child turns 26, they will lose coverage on the last
Employee + Family No Cost No Cost day of their birth month. This is an automated process.

Benefits (In-Network) Plan Coverage

Copays:

Exam $10 Copay

Materials $10 Copay
Frequency: (Based on Date of Service)

Exams Every 12 Months
Lenses Every 12 Months

Frames Every 12 Months
Contact Lenses Every 12 Months
Standard Lenses:

Single Vision $10 Copay

Lined Bifocal $10 Copay

Lined Trifocal $10 Copay

Progressive Lenses $75—$95

Scratch Resistant Coating $0 Copay

Frames:
$130 Retail allowance;
Frames Allowance
then 20% off balance over $130.

$130 Allowance;
Contact Lenses in lieu of eye glasses:
then 15% off balance over $130.

NOTE: This is only a brief overview. Please see the Benefit Summary for more details.
Vision Member Website: www.eyemedvisioncare.com/bcbsokvis or Customer Service : 1-888-381-9727

13