Benefit

Choice of Provider

Any licensed provider

Annual Deductible

None

How the Plan Pays

Plan pays 90% of usual, customary and reasonable (UCR) charges up to a maximum benefit allowance.  You are responsible for the balance of charges.

Exams

90% to $64.50; one each calendar year

Frames

90% of UCR up to $49.50 every two years

Lenses

90% of UCR; one each calendar year
Single Lens: 90% to $58.50
Bifocal lens: 90% to $86.00
Trifocal lens: $90% to $109.00

Contacts
     Medically Necessary
     Cosmetic

90% of UCR - to $192.50
90% of UCR - one each calendar year
90% of UCR - up to $175 in lieu of frames and lenses benefit; one each calendar year