Page 11 - DataMax Benefits Enrollments Guide

Voluntary Vision Benefits

Effective: 10/1/2017

Voluntary Vision Superior Vision

Copays:
Eye Exam $10
Contact Lens Fitting $25
1
Materials $25
Frequency of Services:
Eye Exam Once per 12 months
Frame Once per 24 months
Contact Lens Fitting Once per 12 months
Lenses Once per 12 months
Contact Lenses Once per 12 months
Benefits In-Network Out-of-Network
Materials Benefits:
Exam (Ophthalmologist) Covered by copay Up to $44 allowance
Exam (Optometrist) Covered by copay Up to $39 allowance
Frames $130 retail allowance Up to $52 allowance
2
Contact Lens Fitting (Standard ) Covered by copay Not Covered
2
Contact Lens Fitting (Specialty ) $50 retail allowance Not Covered
Single Vision Covered by copay Up to $26 allowance
Bifocal Lenses Covered by copay Up to $34 allowance
Trifocal Lenses Covered by copay Up to $50 allowance
3
Progressive Lens Upgrade See description Up to $50 allowance
Elective Contact Lenses (Professional Fees &
4
Materials) $130 retail allowance Up to 100 allowance
Medically Necessary Contact Lenses (Professional
4 Covered by copay Up to $210 allowance
Fees & Materials)

1 Materials co-pay applies to lenses and frames only, not contact lenses.
2
Standard Contact Lens Fitting applies to a current contact lens user who wears disposable, daily wear, or
extended wear lenses only. Specialty Contact Lens Fitting applies to new contact wearers and/or a member
who wears toric, gas permeable, or multi-focal lenses.
3
Covered to provider's in-office standard retail lined trifocal amount; member pays difference between
progressive and standard retail lined trifocal, plus applicable copay.
4
Contact Lenses are in lieu of eyeglass lenses and frames benefit.

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