VBA# 2713
Alera Group (Plan D Frequency)
$0 Exam / $0 Materials Copay Dependent Age: 26 (EOBM)
Frequency Type: Last Date of Service
Employee
Spouse
Children
Vision Exam
12 Months 12 Months 12 Months
12 Months 12 Months 12 Months
12 Months 12 Months 12 Months
Lenses Frames
VBA Participating Provider Amount Covered/Benefit (Zero Copay)
Out-of-Network Max Reimbursement (Zero Copay)
Benefits: Employee Can Select Either
Vision Exam (Glasses or Contacts) Clear Standard Lenses (Pair): Single Vision
Covered in Full
$40
Covered in Full Covered in Full Covered in Full Covered in Full Partially-Covered Covered in Full
$40 $50 $50 $75 $75
Bifocal
Blended Bifocal
Trifocal
Progressives
Lenticular
$100
Covered in Full for Persons Up to Age 19
Polycarbonate
N/A
Basic Scratch Coating
Covered in Full
N/A $50
Frame (Wholesale Allowance)
Up to $ 50
-OR- Elective Contacts (in lieu of eyeglass benefits) Material Allowance Elective Fitting Fee and Evaluation -OR- Medically Necessary Contacts Low Vision Aids (Per 24 Months. No Lifetime Max)
Up to $ 110 A 15% off UCR
$110
N/A
Covered in Full B
$320 $650
N/A
-AND- Lasik Surgery (once every 8 years)
N/A $125 Where an “allowance” is shown above, the Member is responsible for paying any charges in excess of the allowance less any applicable copay. Benefits and participation may vary by location, including, but not limited to, Costco® Optical, Pearle Vision, LensCrafters®, Target Optical® and Boscov’s™ A The allowance is applied to all services/materials associated with contact lenses, including, but not limited to, contact fitting, dispensing, cost of the lenses, etc. No guarantee the allowance will cover the entire cost of services and materials. B Requires prior approval. May only be selected in lieu of all other material benefits listed herein. Cost Per Employee Per Month Employee Only Employee + Family $8.70 $17.40
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