|
Optimum |
Focus |
Advantage |
| Vision care services |
Participating Provider |
Nonparticipating Provider |
Participating Provider |
Nonparticipating Provider |
Participating Provider |
Nonparticipating Provider |
| Exam with dilation as necessary |
$10 copay |
$30 allowance |
$10 copay |
$30 allowance |
$10 copay |
$30 allowance |
| Contact lens exam options |
|
|
|
|
|
|
| Standard contact lens fit and follow-up |
Up to $40 |
not available |
Up to $40 |
not available |
not available |
not available |
| Premium contact lens fit and follow-up |
10% off retail |
not available |
10% off retail |
not available |
not available |
not available |
| Frames |
|
|
|
|
|
|
| Discounts available on all frames except when prohibited by the manufacturer. |
$130 allowance, 20% off balance over $100 |
$65 allowance |
$100 allowance, 20% off balance over $100 |
$50 allowance |
40% off retail price |
not available |
| Standard plastic lenses |
|
|
|
|
|
|
| Single vision |
$0 copay |
$25 allowance |
$25 copay |
$25 allowance |
$50 copay |
not available |
| Bifocal |
$0 copay |
$40 allowance |
$25 copay |
$40 allowance |
$75 copay |
not available |
| Trifocal |
$0 copay |
$55 allowance |
$25 copay |
$55 allowance |
$105 copay |
not available |
| Lens options |
|
|
|
|
|
|
| UV coating Tint (solid and gradient) |
$15 copay |
not available |
$15 copay |
not available |
$15 copay |
not available |
| Standard scratch-resistance |
$15 copay |
not available |
$15 copay |
not available |
$15 copay |
not available |
| Standard polycarbonate |
$15 copay |
not available |
$15 copay |
not available |
$15 copay |
not available |
| Standard anti-reflective coating |
$40 copay |
not available |
$40 copay |
not available |
$40 copay |
not available |
| Standard progressive (add-on to bifocal) |
$65 copay |
not available |
$65 copay |
not available |
$65 copay |
not available |
| Other add-ons and services |
20% off retail price |
not available |
20% off retail price |
not available |
20% off retail price |
not available |
| Contact lenses (applies to materials only) |
|
|
|
|
|
|
| Conventional |
$130 allowance, 15% off balance over $130 |
$104 allowance |
$115 allowance, 15% off balance over $115 |
$92 allowance |
15% off retail price |
not available |
| Disposable |
$130 allowance
|
$104 allowance |
$115 allowance
|
$92 allowance |
not available
|
not available |
| Medically necessary |
$0 copay, paid-in-full |
$200 allowance |
$0 copay, paid-in-full |
$200 allowance |
not available |
not available |
| Frequency |
|
|
|
|
|
|
| Examination |
Once every 12 months |
Once every 12 months |
Once every 12 months |
Once every 12 months |
Once every 12 months |
Once every 12 months |
| Frame |
Once every 24 months
|
Once every 24 months |
Once every 24 months
|
Once every 24 months |
Unlimited
|
Unlimited |
| Lenses or contact lenses |
Once every 12 months |
Once every 12 months |
Once every 12 months |
Once every 12 months |
Unlimited |
Unlimited |
