Page 15 - Benefit Guide
P. 15
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 X vision
plan choices through carrier.
Plan Provisions Plan Name Plan Name
Once every 12 months
In-Network Out-of-Network In-Network Out-of-Network
Exam – Once every
12 months $XX copay Up to $XX off $XX copay Up to $XX off
Frames – Once every $XXX allowance Up to $XX off $XXX allowance Up to $XX off
12 months plus XX% off balance Up to $XX off plus XX% off balance Up to $XX off
Lenses – Once every over $XXX over $XXX
12 months
$20 copay $20 copay
Contact Lenses – Once
every 12 months $XXX allowance Up to $XX off $XXX allowance Up to $XX off
plus XX% off balance plus XX% off balance
over $XXX over $XXX
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