Page 18 - Demo

Type of Service In Network Out of Network FrequencyCopay of Eye Exam $10 Copay Amount over $50 once per 12 monthStandard Eyeglass LensesSingle VisionLined BifocalLined TrifocalLenticular$0 Copay$0 Copay$0 Copay$0 CopayAmount over $48Amount over $67Amount over $86Amount over $126one pair per 12 monthFrame Allowance 80% of amount over $150 Amount over $48 one per 24 monthContact Lens Retail AllowanceElectiveTherapeutic80% of amount over $150 Amount over $105Amount over $105one per 12 monthClick Link for SBCSee full plan summary for a more detailed plan explanation along with a list of exclusions and limitations.VISION PLANVision insurance provides coverage for important examinations and corrective needs. It assists in services notcovered by traditional medical insurance plans to improve your sight and quality of life. The benefits of havingvision insurance are extremely helpful in both the short and long term.Believe it or not, vision deficiencies such as nearsightedness, farsightedness, astigmatism and readingdifficulties are not considered medical diagnoses. That is why medical insurance will not cover most eye exams.In most cases, such as an injury; routine vision services are not covered.Eye exams help establish vision conditions and prescribe treatment, such as corrective eyewear. Having visioninsurance helps cover those visits and associated costs, helping you keep your eyes healthy.Your Vision Benefits Explained:SBC (Plan Summary)Refer to your Summary of BenefitCoverage (SBC) for full policy details,limitations, and exclusions.18