Page 44 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

VISION CARE 130
12/12/24
12/12/24
12/12/12
Frequencies
Eye exam10
12 months
12 months
12 months
Spectacle lenses/frames
12 months/24 months
months
12 months/24 months
months
12 12 months/12 months
months
Contact lenses 12 months
24
months
12 months
Copays
Eye exam/spectacle lenses $10/$10
$10/$25
$0/$0
Frame
Non-collection frame allowance (retail)
Up to to $130 or up to to $180 at Visionworks plus 20% off any overage9
Up to to $130 or up to to $180 at Visionworks plus 20% off any overage9
Up to to $130 or up to to $180 at Visionworks plus 20% off any overage9
Davis Vision Frame
Collection in lieu of allowance fashion/designer/premier
Included/Included/$25
Included/Included/$25
Included/Included/$25
Contact Lenses
Collection contact lenses (in lieu of allowance)
2 boxes – planned replacement 4
boxes – disposable
2 boxes – planned replacement 4
boxes – disposable
2 boxes – planned replacement 4
boxes – disposable
Collection evaluation fitting follow-up care
Included Included Included Non-collection contact lenses: Materials allowance8
Up to $130 15% discount on any overage Up to $130 15% discount on any overage Up to $130 15% discount on any overage Non-collection evaluation fitting and and follow-up care
standard and specialty lens types
Standard — Covered in Full Specialty & Disposable — $60 Program Allowance 15% discount on overages (Only Included with purchase of Non-Collection contact lenses)
Standard — Covered in Full Specialty & Disposable — $60 Program Allowance 15% discount on overages (Only Included with purchase of Non-Collection contact lenses)
Standard — Covered in Full Specialty & Disposable — $60 Program Allowance 15% discount on overages (Only Included with purchase of Non-Collection contact lenses)
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