| Vision Care Services | In Network |
| Exam (w/ dilation as necessary) | $10 copay |
| Frames | $0 Copay, $130 Allowance, 20% off balance over $130 |
| Plastic Lenses | |
|
Single Vision Plastic Lenses |
$25 Copay |
|
Bifocal Plastic Lenses |
$25 Copay |
|
Contact Lenses |
|
|
Conventional Contact Lenses |
$0 Copay, $130 allowance, 15% off balance over $130 |
| Disposable Contact Lenses | $0 Copay, $130 allowance, plus balance over $130 |
| Medically Necessary Contact Lenses | $0 Copay, Paid-in-Full |
| Laser Vision Correction | |
| LASIK or PRK (From US Laser Network) | 15% off Retail Price or 5% off promotional price |
| Frequency | |
| Examination | Once every 12 months |
| Lenses (In lieu of contact lenses.) | Once every 12 months |
| Contacts (In lieu of lenses.) | Once every 12 months |
| Frame | Once every 12 months |
| Additional Discounts | |
| Complete pair of prescription eyeglasses | 40% OFF |
| Non-prescription sunglasses | 20% OFF |
| Remaining balance beyond plan coverage | 20% OFF |