Page 93 - APPENDICES for Diane Falten

VISION

Routine eye exam In-network: $0 copay Limits apply

Out-of-network: 30%
coinsurance

Contact lenses In-network: $0 copay
Out-of-network: $0 copay

Eyeglasses (frames & In-network: $0 copay
lenses) Out-of-network: $0 copay

Eyeglass frames only In-network: $0 copay
Out-of-network: $0 copay

Eyeglass lenses only In-network: $0 copay
Out-of-network: $0 copay

Upgrades In-network: $0 copay
Out-of-network: $0 copay

MEDICALLY-APPROVED NON-OPIOID PAIN MANAGEMENT SERVICES

Chiropractic services Not covered

Acupuncture Some coverage

Massage therapy Not covered

Alternative therapies Some coverage