Page 85 - Appendices for Eric Hartman
P. 85

VISION





       Routine eye exam                       In-network: $0 copay                   Limits apply
                                              Out-of-network: 30%
                                              coinsurance






       Contact lenses                         In-network: $0 copay                   Limits apply
                                              Out-of-network: 50%
                                              coinsurance





       Eyeglasses (frames &                   In-network: $0 copay                   Limits apply
       lenses)                                Out-of-network: 50%

                                              coinsurance





       Eyeglass frames only                   In-network: $0 copay                   Limits apply
                                              Out-of-network: 50%
                                              coinsurance






       Eyeglass lenses only                   In-network: $0 copay                   Limits apply
                                              Out-of-network: 50%
                                              coinsurance





       Upgrades                               Not covered
   80   81   82   83   84   85   86   87   88   89   90