Page 12 - MCU Benefits Guide

Voluntary Vision Benefits

Blue 20/20 with EyeMed
Voluntary Vision
Network Provider Non-network
Provider
Copays:
Eye Exam $10 $39
Materials $25 See Materials Benefit
below
Frequency of Services: Benefit Period runs from 2/1-1/31
Eye Exam Once every 12 months

Lenses Once every 12 months

Frames Once every 24 months
Contact Lenses Once every 12 months ( in lieu of frames)

Materials Benefits:
Covered in full after
Single Vision copay $25 allowance
Covered in full after
Bifocal Lenses $39 allowance
copay
Trifocal Lenses Covered in full after $63 allowance
copay
Lenticular Lenses Covered in full after $63 allowance
copay
Covered up to $130,
Blue 20/20 covers
Frames* $65 allowance
20% of balance over
allowance

Conventional: Covered
up to $130, Blue 20/20
covers 15% of balance
over allowance
Elective Contact Lenses (Professional
$104 allowance
Fees & Materials)* Disposable: Covered up

to $130, Blue 20/20
covers 0% of balance
over allowance
(member pays 100%)
Medically Necessary Contact Lenses Paid in full $200 allowance
(Professional Fees & Materials)
*The member is responsible for paying any charges in excess of this allowance
Please see Plan Design documents for full listing of coverage.

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