Page 9 - OrangeTheory Benefits Guide 07-2019_FINAL - NonCA

Vision Benefits

MetLife | PPO Vision Plan
The MetLife vision plan provides professional vision care and high quality lenses and frames through a broad network of
optical specialists. You will receive richer benefits if you utilize a network provider. If you utilize a non‐network provider, you
will be responsible to pay all charges at the time of your appointment and will be required to file an itemized claim with
MetLife.

MetLife
Plan Type:
PPO Plan
Network Type: In-Network Out of Network

Vision Benefits
Copay
- Examination (Every 12 Months) $10 Copay Reimbursed up to $45

Lenses (Every 12 Months)
- Single Vision $25 Copay Reimbursed up to $30
- Bifocal $25 Copay Reimbursed up to $50
- Trifocal $25 Copay Reimbursed up to $65
- Lenticular $25 Copay Reimbursed up to $100

In-Network: $25 Copay, $130 Allowance
Frames (Every 12 Months) Costco: $25 Copay, $70 Allowance; 20% Reimbursed up to $70
off balance over Copay
Contact Lenses (Every 12 Months) In Lieu of Frames and Lenses
- Elective $130 Allowance Reimbursed up to $105
- Medically Necessary $25 Copay, Covered in Full Reimbursed up to $210

15% off retail price or 5% off promotion
Laser Vision Correction N/A
price only at participating locations

Note: The MetLife Vision network includes access to independent ophthalmologists and optometrists, as well as Costco
Optical, Pearle Vision, America’s Best, Cohen’s, and VisionWorks retail stores.

Finding In-Network Vision Providers

Go to www.metlife.com/insurance/vision-insurance or call (855) 638-3931

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