OPTICARE PLAN:
0-10-140C
| Products/Services | Select Network | Broad Network | Out-Of-Network |
|---|---|---|---|
| Eye Exam | |||
| Eyeglass exam | 100% Covered | $10 Co-pay | $40 Allowance |
| Contact exam | 100% Covered | $10 Co-pay | $40 Allowance |
| Routine Dilation | 100% Covered | Retail | Included above |
| Contact Fitting | 100% Covered | Retail | Included above |
| Standard Plastic Lenses | |||
| Single Vision | 100% 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-pay | 25% Discount | |
| Coatings | |||
| Scratch Resistant Coating | 100% Covered | $10 Co-pay | |
| Ultra Violet protection | 100% Covered | $10 Co-pay | |
| Other Options | Up 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 Year | Up 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% off | Retail | |
| Disposables | Up to 10% off | Retail | |
| Frequency | |||
| Exams, Lenses, Frames, Contacts | Every 12 months | Every 12 months | Every 12 months |
| Refractive Surgery | |||
| LASIK | 20% Off Retail | Not Covered | Not Covered |