Service
|
EyeMed Providers
(in-network coverage) |
Non-EyeMed Providers
(out-of-network coverage) |
Exam (once every 12 months)
|
$10 copay
|
Covered up to $40
|
| Frames (once every 12 months) |
- $0 co-pay
- $130 allowance
- 20% off balance
|
Covered up to $65
|
Standard Plastic Lenses
(once every 12 months)
|
- Single Vision: $10 copay
- Bifocal: $10 copay
- Trifocal: $10 copay
|
Covered up to:
- Single Vision: up to $25
- Bifocal: up to $40
- Trifocal: up to $55
|
Lens Options (once every
12 months)
|
- UV Coating: $0
- Tint: $15
- Standard Scratch Resistance: $0
- Standard Polycarboncate: $0
- Standard Anti-Reflective Coating: $45
- Standard Progressive (add-on to bi-focal): $75
- Other Add-Ons and Services: 20% off retail
|
- UV Coating: Up to $5
- Tint: N/A
- Standard Scratch Resistance: Up to $5
- Standard Polycarboncate: Up to $5
- Standard Anti-Reflective Coating: N/A
- Standard Progressive (add-on to bi-focal): Up
to $40
- Other Add-Ons and Services: N/A
|
| Contacts Lenses |
- Conventional: $0 copay, $125 allowance, 15%off
balance
- Disposable: $0 copay, $125 allowance
- Medically necessary: Paid in Full
- Contact Lens Fit and Follow-Up: Up to $55
|
- Conventional: Up to $100
- Disposable: Up to $100
- Medically necessary: Up to $200
- Contact Lens Fit and Follow-Up: N/A
|