SILVER COMPLETE Allowance Summary USD 466 Scott County Schools
VCD Standard Network
VCD PLUS Network
Out of Network
Benefit Frequency Eye Exam
12 Months 24 Months 12 Months 12 Months
12 Months 24 Months 12 Months 12 Months
12 Months 24 Months 12 Months 12 Months
Frames Lenses Contacts
Member Fees Eye Exam
$15.00 $15.00 $25.00
$15.00 $15.00 $25.00
$0 $0 $0 $0 $0
Glasses
Polycarbonate for Kids
Contacts
$0 $0
$0 $0
Lasik
Eye Exam (amount included after exam fee listed above) Comprehensive eye health examination including refraction and dilation Flexible Exam Benefit In the event you have an eye exam included with another plan, Vision Care Direct allows you to use your exam benefit for other services or materials. A credit will be applied to your bill at time of service toward non-covered items. Frames Frame allowance toward retail price of any frame in provider’s office.
100%
100%
$50
$65
$65
$0
$100/$160/$200
$100/$160/$200
$60
Lenses (amount included after glasses fee listed above) Single Vision: CR-39 in glass or plastic
100% 100% 100%
100% 100% 100%
$50 $75
Bifocal: CR-39 in glass or plastic Trifocal: CR-39 in glass or plastic
$100
Up to retail price of lined trifocal Up to retail price of lined trifocal
Standard Progressive Lenses
100%
$100
Up to retail price of standard progressive
Premium Progressive Lenses
$100
Lens Options Scratch Resistant Coating
Not Included Not Included Not Included Not Included
100% 100% 100% 100% 100%
$0 $0 $0 $0 $0 $0
Ultraviolet Coating
Anti-Reflective Coating
Oil & Water Resistant Coating
Polycarbonate for Kids (after PK fee listed above)
100%
Polycarbonate for Adults
Not Included
Not Included
Contacts Elective Contact Lenses: In lieu of glasses. Can be used toward multi-focal contacts and contact lens fitting fees. Medically Necessary Contact Lenses: Requires prior authorization from your doctor to the Vision Care Direct Medical Director. Medically necessary is defined as 1) Keratoconus; or 2) monocular and/or binocular aphakia
$105/$160/$200
$105/$160/$200
$80
$750
$750
$80
Lasik In lieu of glasses and contacts. Allowance of $200 toward Lasik procedure in the form of a reimbursement directly to the member. To file for Lasik reimbursement, go to members.visioncaredirect.com/lasik GENERAL LIMITATIONS AND EXCLUSIONS: Vision Care Direct guarantees benefits only for the products/services listed above. Any charges incurred for items not detailed here, or that are incurred after the membership ends, are the sole responsibility of the member. Out of network benefits are provided in the form of a reimbursement directly to the member. To file for an out of network reimbursement, visit members.visioncaredirect.com/oon.
SIMPLE. FLEXIBLE. AFFORDABLE.
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