Vision
Healthy eyes and clear vision are an important part of your overall health and quality of life. You may enroll yourself and your eligible dependents or you may waive vision coverage. You do not have to be enrolled in medical coverage to elect vision coverage or cover the same dependents under medical and vision.
Although vision care services and supplies are covered in-network and out-of-network, your benefits are generally greater when you use in-network providers. Your costs are based on the family members you choose to cover.
Plan Information
Plan Name: The Standard Vision
Policy Number: 756980
Effective Date: 11/01/2024
Provider Network: Vision Standard Plan
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Exams
$10 copay
Single Vision Lenses
$0 after $10 copay
Frames
Balance over $200 allowance
Contacts (in lieu of glasses)
Balance over $200 allowance
Frequency
Exams
Once every 12 months
Lenses
Once every 12 months
Frames
Once every 12 months
Contacts
Once every 12 months
Out-of-Network Reimbursement
Exams
$10 copay
Single Vision Lenses
Reimbursed up to $30
Frames
Reimbursed up to $145
Contacts (in lieu of glasses)
Reimbursed up to $70
Frequency
Exams
Once every 12 months
Lenses
Once every 12 months
Frames
Once every 12 months
Contacts
Once every 12 months
Plan Documents
Contact Information
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
In-Network
Exams
$10 copay
Single Vision Lenses
$0 after $10 copay
Frames
Balance over $200 allowance
Contacts (in lieu of glasses)
Balance over $200 allowance
Frequency
Exams
Once every 12 months
Lenses
Once every 12 months
Frames
Once every 12 months
Contacts
Once every 12 months
Out-of-Network
Exams
$10 copay
Single Vision Lenses
Reimbursed up to $30
Frames
Reimbursed up to $145
Contacts (in lieu of glasses)
Reimbursed up to $70
Frequency
Exams
Once every 12 months
Lenses
Once every 12 months
Frames
Once every 12 months
Contacts
Once every 12 months