This is a summary of the vision plan. For complete details, see the Summary of Benefits.

Covered Services

Exam

Frame

Spectacle Lenses
(Standard - Single Vision, Bifocal, Trifocal, Lenticular)

Contact Lenses**

LASIK

Rates

Member Only
Member + Family

Amount Covered*

Covered 100% (after $10 copay)

$50 wholesale allowance


Covered 100%***

$110 Allowance

$100 one-time allowance

$8.48 per month
$19.50 per month

Frequency

Once Every 12 Months

Once Every 24 Months


Once Every 12 Months

Once Every 12 Months

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summary of benefits


*Amount covered at a preferred provider
**Contact lenses allowance takes the place of spectacle lenses and a frame for that plan period.
*** Covered in full after the material copay of $25 is met.