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In Network
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Out of Network
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Comprehensive Exam (Optometrist)
Comprehensive Exam (Ophthalmologist) |
Covered in full after $10 copayment
Covered in full after $10 copayment |
$35 allowance |
| Lenses:
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After $15 copay
After $15 copay
After $15 copay |
$25 allowance
$40 allowance
$50 allowance |
Contact Lenses:
- Medically necessary
- Cosmetic (elective)*
*Contact lenses are in lieu of eyeglass lenses and frames benefit. |
$10 copay up to $150
*The insured is responsible for paying any charges in excess of this allowance. |
$150 allowance
$80 allowance |
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Frames:
*Frames are in lieu of contact lenses and contact lens benefit.
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Up to $150
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$70 allowance
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