Page 45 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

VISION CARE 150
12/12/24
12/12/12
Frequencies
Eye exam10
12 months
12 months
Spectacle lenses/frames
12 months/24 months
months
12 12 months/12 months
months
Contact lenses 12 months
12 months
Copays
Eye exam/spectacle lenses $10/$25
$0/$0
Frame
Non-collection frame allowance (retail)
Up to to $150 or up to to $200 at Visionworks plus 20% off any overage9
Up to to $150 or up to to $200 at Visionworks plus 20% off on 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 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 2021 Large Group Plans 43
Please see footnotes on page 46