Page 67 - APPENDICES for Fred Falten

Limits apply

VISION

Routine eye exam
In-network: $0 copay

Limits apply

Contact lenses
In-network: $0 copay

Eyeglasses (frames & lenses)
In-network: $0 copay

Eyeglass frames (only)

In-network: $0 copay

Eyeglass lenses (only)
In-network: $0 copay

Upgrades
In-network: $0 copay

MEDICALLY-APPROVED NON-OPIOID PAIN MANAGEMENT SERVICES

Chiropractic services
Not covered

Acupuncture

Some coverage

Massage therapy
Not covered