Page 43 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance
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VISION CARE 150
12/12/24
12/12/12
Frequencies
Eye exam10
12 months
12 months
Spectacle lenses/frames
12 months/24 months
12 months/12 months
Contact lenses
12 months
12 months
Copays
Eye exam/spectacle lenses
$10/$25
$0/$0
Frame
Non-collection frame allowance (retail)
Up to $150 or up to $200 at Visionworks, plus 20% off any overage9
Up to $150 or up to $200 at Visionworks, plus 20% off on any overage9
Davis Vision Frame Collection in lieu
of allowance; fashion/designer/premier
Included/Included/Included
Included/Included/Included
Contact Lenses
Collection contact lenses (in lieu of allowance
4 boxes – planned replacement 8 boxes – disposable
4 boxes – planned replacement 8 boxes – disposable
Collection evaluation, fitting, follow-up care
Included
Included
Non-collection contact lenses: Materials Allowance8
Up to $150;
15% discount on any overage
Up to $150;
15% discount on any overage
Non-collection evaluation, fitting and follow-up care; standard and specialty lens types
Standard — Covered in Full Specialty & Disposable — $60 Program Allowance; 15% discount on overages
Standard — Covered in Full Specialty & Disposable — $60 Program Allowance; 15% discount on overages
Please see footnotes on page 44
2021 Large Group Plans 41
