VISION PLAN
SUMMARY OF COVERAGE
Plan Features
Vision Plan
IN NETWORK
OUT OF NETWORK
$20 copay
Up to $20
Vision Exam
Lenses
Single Bifocal Trifocal Polycarbonate (adults & children)
$20copay $20 copay $20 copay Up to $40
Up to $15 Up to $30 Up to $60 Not Covered
$105 allowance
Up to $50
Frames
$105 allowance + 15% off remaining No Charge, after $20 copay
Up to $175 Up to $200
Elective Contact Lenses Medically Necessary
Frequency Limit (Months) Exam
Every 12 Months Every 12 Months Every 24 Months Every 12 Months
Lenses Frames Contacts
Up to 15% Off
No discounts
Laser Vision Correction
To find an in-network provider, visit www.aetnavision.com or call (877) 973-3238 . Aetna utilizes the EyeMed network
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PRIVATE PREP BENEFITS GUIDE
VISION PLAN I
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