VISION PLAN
SUMMARY OF COVERAGE
Guardian Vision Features
Plan Features IN NETWORK
Vision Exam
$10
Lenses Single
$10 $10 $10
Bifocal Trifocal
Frames
80% of amount over $120
Elective Contact Lenses Medically Necessary Contact Lenses Frequency (Months) Exam
$120 max benefit
100%
Every 12 Months Every 12 Months Every 12 Months Every 12 Months
Lenses Frames Contacts
OUT OF NETWORK
Vision Exam
$46 max benefit
Lenses Single
$47 max benefit $66 max benefit $85 max benefit $47 max benefit $120 max benefit $210 max benefit
Bifocal Trifocal
Frames
Elective Contact Lenses Medically Necessary Contact Lenses
22
VISION PLAN I
Callen Lorde BENEFITS GUIDE
22
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