Page 13 - 2022 Drive Open Enrollment Guide - Non Union

Vision plan

The vision plan provides coverage for routine eye exams and pays for all or a portion of the cost of glasses or contact
lenses. You can choose any provider; however, you always save money if you see in-network providers. We offer vision
through Empire. To locate an Empire provider refer to www.empireblue.com and search using the “Blue View Vision” network.

Base Plan High Plan
Plan Provisions
In-Network Out-of-Network In-Network Out-of-Network

Exam $20 copay Up to $42 $10 copay Up to $42

$130 allowance plus $150 allowance plus
Frames 20% discount off Up to $45 20% discount off Up to $45
balance balance
Frequency:
Exam 12 months 12 months
Lenses or Contacts 12 months 12 months
Frames 24 months 12 months

Lenses:
Single Vision Up to $40 Up to $40
$20 $10
Bifocal Up to $60 Up to $60
Trifocal Up to $80 Up to $80

$130 allowance plus $150 allowance plus
Elective Contacts in lieu of 15% discount off Up to $105 15% discount off Up to $105
Glasses
balance balance

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