Mid-America Apartments C1 PPO Comprehensive Plan
In-Network Coverage Includes** : •
What’s Not Covered: • Orthoptic or vision training and any associated supplemental testing • Medical or surgical treatment of the eyes • Any eye examination, or any corrective eyewear, required by an employer as a condition of employment • Any injury or illness when paid or payable by Workers’ Compensation or similar law, or which is work-related • Charges in excess of the usual and customary charge for the Service or Materials • Charges incurred after the policy ends or the insured’s coverage under the policy ends, except as stated in the policy • Experimental or non-conventional treatment or device • Magnification or low vision aids not shown as covered in the Schedule of Vision Coverage • Any non-prescription (minimum Rx required) eyeglasses, includes frame, lenses, or contact lenses • Spectacle lens treatments, “add - ons”, or lens coatings not shown as covered in the Schedule of Vision Coverage • Prescription sunglasses lens “add - ons”, or lens coatings not shown as covered in the Schedule of Vision Coverage • Two pair of glasses, in lieu of bifocals or trifocals • Safety glasses or lenses required for employment not shown as covered in the Schedule of Vision Coverage • VDT (video display terminal)/computer eyeglass benefit • Claims submitted and received in excess of twelve (12) months from the original Date of Service
One vision and eye health evaluation including but not limited to eye health examination, dilation, refraction, and prescription for glasses; • One pair of standard prescription plastic or glass lenses, all ranges of prescriptions (powers and prisms) including Oversize, Rose #1 or #2 Solid Tint and Polycarbonate lenses < 19 years of age. o 20% savings on all additional lens enhancements/ option you choose for your lenses, not shown on the Schedule of Vision Coverage above. • One pair of Elective conventional contact lenses or a single purchase of a supply of disposable contact lenses – in lieu of lenses and frame benefit, (may not receive contact lenses and frames in same benefit year). • Coverage for Therapeutic contact lenses will be provided when visual acuity cannot be corrected to 20/70 in the better eye with eyeglasses and the fitting of the contact lenses would obtain this level of visual acuity; and in certain cases of anisometropia, keratoconus, or aphakis; as determined and documented by your Vision eye care professional. Contact lenses fitted for other therapeutic purposes or the narrowing of visual fields due to high minus or plus correction will be covered in accordance with the Elective contact lens coverage shown on the Schedule of Vision Coverage. • One frame for prescription lenses – frame of choice covered up to retail plan allowance, plus a 20% savings on amount that exceeds frame allowance; ** Coverage may vary at participating discount retail and membership club optical locations, please contact Customer Service for specific coverage information. *** Provider participation is 100% voluntary; please check with your Eye Care Professional for any offered discounts.
01/01/2025 Tennessee
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