Page 13 - MCU Benefits Enrollments Guide

Voluntary Vision Benefits Group #9859240

In Network Copayment Out of Network Frequency of Service
Exam: $10 Allowance Exam: Every 12 months
Materials: $10 (applies to Exam: $39 allowance Lenses: Every 12 months
lens & frames only) Materials: See below Frames: Every 24 months
Contact Lenses: Every 12 months (In Lieu of
Frames)
Benefit after Copay In-Network Out-of-Network

Standard Lenses: $25 copay $25 allowance
Single Vision
Bifocal Lenses
$25 Copay $39 allowance
Trifocal Lenses
$25 Copay $63 allowance

Lenticular Lenses
$25 Copay $63 allowance
Frames-Standard** Covered up to $130, Blue
20/20 covers 20% of $65 allowance
balance over allowance
Contact Lenses:*
Paid in Full $200 allowance
Medically Necessary
Cosmetic-Elective**
Conventional Covered up to $130, Blue
20/20 covers 15% of
balance over allowance

$104 allowance
Disposable
Covered up to $130, Blue
20/20 covers 0% of
balance over allowance
(member pays 100%)
**The member is responsible for paying any charges in excess of this allowance
Please see Plan Design documents for full listing of coverage.
Blue 20/20 Vision network is with EyeMed.

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