Page 26 - 2020 Benefits Guide

Vision Plan

Basic Plan*
Exam with Dilation as Necessary $10 Copay
Exam Options:
Members <19: Standard Contact Lens Fit & Follow-Up N/A
Members <19: Premium Contact Lens Fit & Follow-Up N/A
Adults: Standard Contact Lens Fit & Follow-Up N/A
Adults: Premium Contact Lens Fit & Follow-Up N/A
Frames: Any available frame at provider location 35% off retail
Standard Plastic Lenses:
Single Vision $50 Copay
Bifocal $70 Copay
Trifocal $105 Copay
Lenticular N/A
Standard Progressive Lens $135 Copay
Premium Progressive Lens N/A
Lens Options:
UV Treatment $15 Copay
Tint (Solid and Gradient),Standard Plastic Scratch Coating $15 Copay
Standard Polycarbonate – Adults and Kids $40 Copay
Standard Polycarbonate – Kids < 19 $40 Copay
Standard Anti-Reflective Coating $45 Copay
Polarized 20% off Retail
Photochromic/Transitions Plastic – Adults N/A
Photochromic/Transitions Plastic – Kids <19 N/A
Other Add-Ons 20% off Retail

Contact Lenses (Contact lens allowance includes materials only)
Conventional 15% off Retail
Disposable N/A
Medically Necessary N/A
Laser Vision Correction 15% off Retail
Lasik or PRK from U.S. Laser Network Price or 5% off
promotional price
Additional Pairs Benefit: N/A

Bi-Weekly Payroll Deductions Weekly Payroll Deductions
Basic Enhanced Basic Enhanced
Vision Vision Vision Vision
Employee Only $0.54 $2.33 Employee Only $0.28 $1.19
Employee + Spouse $1.04 $4.44 Employee + Spouse $0.53 $2.26
Employee + Children $1.21 $5.19 Employee + Children $0.62 $2.64
Employee + Family $1.79 $7.67 Employee + Family $0.91 $3.91

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