Welborn Health Plans Vision Benefits
Medicare Cost Vision Plan 0001 Voluntary Opt-Out
PLAN DESCRIPTION 2011
| Benefits | In-Network |
|---|---|
| Eye Examination | Covered in Full after Co-pay |
| Spectacle Lenses Standard Single Vision Standard Bifocal Standard Trifocal Standard Lenticular |
Covered in Full after Co-pay |
| Lens Options | Preferred Pricing* |
| Frame | Covered in Full $35 Wholesale Allowance (approximately $75 - $100 retail value) |
| Contact Lenses** Elective Medically Necessary |
$110 Allowance |
*Average Savings of 20% off the provider's usual and customary fees.
**In lieu of spectacle lenses and frames
Avesis Network
| Benefit | Co-pay |
|---|---|
| Vision Examination | $10.00 |
| Prescription Glasses (Frames/Lenses) | $20.00 |
| Benefit | Frequency |
|---|---|
| Vision Examination | 12 Months |
| Prescription Glasses (Frames/Lenses) | 12 Months |
| Frame | 24 Months |
| Contact Lenses | 12 Months |