| Routine Exam (including dilation) |
Plan Pay is $45 (less patient copay) |
| Fitting/Eval |
Plan Pay is 80% of U&C – unless plan states patient responsibility |
| Frames (Based on specific Member’s allowance) Standard & Deluxe |
Plan Pay is 50% of frame retail price (less patient responsibility). Member pays the balance over their allowance |
| Lenses |
| V2100 Single vision lenses (Std plastic) |
Plan Pays $35 |
| V2200 Bifocal lenses (std plastic) |
Plan Pays $50 |
| V2300 Trifocal lenses (std plastic) |
Plan Pays $75 |
| Progressive allowance (may vary by plan) |
Covered for Basic Progressive Only – see below for details |
| V2781 Standard Progressive |
Plan Pays $90 less applicable member copay & Member pay is Copay Only (Cap-Off Allowance of $140 Retail) |
| V2781 Premium Progressive |
Plan Pays $110 less applicable member copay & Member pays: Copay PLUS amount over Retail difference of the Std & Prem Progressive at 20% Discount if available. (If Standard/Prem is over $140 Cap-Off Allowance, Member Pays difference over $140 in addition to their Stan Progressive Co-Pay) |
| Contact Lenses |
| V2500-V2530 |
Plan Pays 90% of Member’s Retail Allowance. Member pays balance over allowance |
| Add-Ons and Upgrades |
| Materials |
|
| V2784 Polycarbonate |
Patient responsibility less any available discounts by provider |
| V2783 High Index |
Patient responsibility less any available discounts by provider |
| Coatings |
|
| V2755 UV Coating |
Included- Plan Pays $10 (less patient copay) |
| V2760 Standard scratch resistance coating |
Included- Plan Pays $10 (less patient copay) |
| V2745 Solid or Gradient Tint |
Patient responsibility less any available discounts by provider |
| V2750 Standard Anti-reflective coating |
Patient responsibility less any available discounts by provider |
| V2750 Premium Anti-reflective coating |
Patient responsibility less any available discounts by provider |
| V2762 Polarized |
Patient responsibility less any available discounts by provider |
| V2744 Transition |
Patient responsibility less any available discounts by provider |
| V2799 Edge Coating/Miscellanous |
Patient responsibility less any available discounts by provider |
| Other |
| All other options/Upgrades & non Rx Sun’s |
Patient responsibility less any available discounts by provider |
| Other ancillary products/ solutions |
Patient responsibility less any available discounts by provider |
