Page 63 - 2022 Large Group benefits

Vision Care 150
Option 1 Employer paid & voluntary
Option 2 Funding type
Employer paid & voluntary
Copayments
Eye examination Spectacle lenses
Eye examination1
Spectacle lenses
Frame
Contact lens evaluation fitting & follow-up care
Contact lenses
(in lieu of eyeglasses)
$10 $25
12 months
12 months
24 months
12 months
12 months
• • Fully covered or or or or or minimal copay for Davis Vision Exclusive Collection of of frames 2 2 or or or or or • • • $150 frame frame frame allowance allowance plus 20% off the overage at at in-network providers or or or or or • • $200 frame frame allowance allowance at Visionworks
$0
Frequency
Frame
allowance options $0
12 months
12 months
12 months
12 months
12 months
Fully covered lens options • Clear plastic single-vision lined bifocal trifocal or lenticular lenses
(any prescription) • Ultraviolet coating
• Scratch-resistant coating
• Oversize lenses
• Polycarbonate lenses3 5 • Tinting of plastic lenses4
• Standard progressive lenses5
Need vision coverage?
If If you you you you you choose choose choose DPOS or POS POS medical medical plans
plans
routine eye exams are included and and you you you you you can can choose choose choose to enhance your benefit with a a a a a a a a a a a a a a a a a a plan plan plan plan that includes frames and and lenses
If If you you you you you offer PPO medical medical plans
plans
plans
you you you you you can can choose choose choose any one of our our vision plans
for complete coverage 1 Inclusive of of dilation when professionally indicated 2 Allowances are are up to the amount shown for for each plan type
3
3
Polycarbonate lenses
are are are are covered in full for for dependent children monocular patients patients and and patients patients with prescriptions +/- 6 00 diopters or or or greater 4 Vision Vision Vision Care Care Care 130
and Vision Vision Vision Care Care Care 150
150
only only 5 5 Vision Vision Vision Care Care 150
only 2022 Large Group Plans | Independence Blue Cross 62