OPTICARE PLAN:

0-10-140C

Products/ServicesSelect NetworkBroad NetworkOut-Of-Network
Eye Exam
Eyeglass exam100% Covered$10 Co-pay$40 Allowance
Contact exam100% Covered$10 Co-pay$40 Allowance
Routine Dilation100% CoveredRetailIncluded above
Contact Fitting100% CoveredRetailIncluded above
Standard Plastic Lenses
Single Vision100% Covered$10 Co-pay$75 Allowance for lenses, options, and
coatings
Bifocal (FT 28)100% Covered$10 Co-pay$75 Allowance for lenses, options, and
coatings
Trifocal (FT 7x28)100% Covered$10 Co-pay$75 Allowance for lenses, options, and
coatings
Lens Options
Progressive (Standard plastic no-line)$10 Co-pay$50 Co-pay
Premium Progressive Options $80 Co-pay$100 Co-pay
Polycarbonate $20 Co-pay$40 Co-pay
Anti-Reflective$40 Co-pay$45 Co-pay
High Index$80 Co-pay25% Discount
Coatings
Scratch Resistant Coating100% Covered$10 Co-pay
Ultra Violet protection100% Covered$10 Co-pay
Other OptionsUp to 25%
Discount
Up to 25%
Discount
Edge polish, tints, mirrors, etc,
Frames
Allowance Based on Retail Pricing $140 Allowance$130 Allowance$75 Allowance
Additional Eyewear
Additional Pairs of Glasses Throughout the YearUp to 50% Off
Retail
Up to 25% Off
Retail
Contacts
Contact benefits is in lieu of lens and frame
benefit.
$140 Allowance$130 Allowance$105 Allowance
Additional contact purchases:
Conventional Up to 20% offRetail
Disposables Up to 10% offRetail
Frequency
Exams, Lenses, Frames, Contacts Every 12 monthsEvery 12 monthsEvery 12 months
Refractive Surgery
LASIK20% Off RetailNot CoveredNot Covered