VISION
ADD-ON BENEFIT - Benefit Period Every 12 months
BENEFITS
In-Network
Non-Network
Spectacle exam
$15 copay
$15 maximum
Contact lens exam
$15 co-pay + any amount over spectacle exam
$15 maximum
Frames - One Pair
Covered Up to $10015% off amount over $100
$30 maximum
Lenses (One
Pair - Uncoated plastic)
Single Vision
$15 co-pay
$10 maximum
Bifocal
$20 maximum
Trifocal
$30 maximum
Lenticular
$40 maximum
Contact lenses (instead
of lenses and frames)
Cosmetic
$15 co-pay (Up to $100)
$40 maximum
Medically necessary
$15 co-pay (Up to $200)
$75 maximum
Disposable
$15 co-pay (Up to $100)
$40 maximum
If a Cole Vision provider
is used, members are entitled to a discount in addition to the
lens co-pays listed above. The discount applies to items whether
or not they are covered as part of a vision plan.
Check current Vision Plan listings for various Cole Vision providers
in your area.
