VISION PLAN
SUMMARY OF COVERAGE
Vision Benefit
In Network
Out of Network
Frequency
Once every 12 months Once every 12 months Once every 24 months
Examination
$10 copay
Up to $30
Lenses
$15 copay
Up to $25 - $60
Frames
Up to $130
Up to $65
Once every 12 months
Med. Nec. Up to $0 Elective: Up to $130
Med. Nec. Up to $200 Elective: Up to $104
Contacts
Bi-Weekly Contribution
Employee Only
$0.99
Employee and Spouse
$2.46
Employee and Child
$3.05
Family
$4.79
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VISION PLAN I
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