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Type of Service In Network Out of Network FrequencyCopay of Eye Exam $10 Copay Up to $45 Allowance once per 12 monthStandard Eyeglass LensesSingle VisionLined BifocalLined TrifocalLenticular$10 Copay$10 Copay$10 Copay$10 Copay$10 CopayNot CoveredUp to $30 AllowanceUp to $50 AllowanceUp to $65 AllowanceUp to $100 Allowanceone pair per 12 monthFrame Allowance 100% up to $150 Retail Allowance Up to $70 Allowance one per 12 monthContact Lens Retail AllowanceElectiveTherapeutic100% up to $150 Retail AllowanceCovered at 100%Up to $105 AllowanceUp to $210 Allowanceone per 12 monthSee 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:25