2024 Plan Details

• You may apply your frame appliance toward non-prescription sunglasses or blue light filtering glasses.
• In this case, service intervals for both frames and lenses will apply when in-network¹
  

• One additional comprehensive eye exam less any applicable copayment

• One additional pair of lenses, necessary contact lenses or elective contact lenses less any applicable copayment if:

–the new prescription differs from the original by at least a .50 diopter sphere or cylinder, or

–there is a change in the axis of 15 degrees or more, or

–there is a .5 prism diopter change in at least one eye

• Once per calendar year intervals for exam, frames and lenses/contacts

• Applies only to covered children under age 18

• Additional coverage for members diagnosed with type 1 or type 2 diabetes, glaucoma and age-related macular degeneration (AMD)
• Preventive retinal screenings for members with diabetes but don’t show signs of diabetic eye disease
• Exam: covered in full after $20 copay
• Special Ophthalmological Services covered in full

• Additional benefits for members who are not legally blind but whose eyesight cannot be corrected to 20/70 with the use of optical lenses; not available at retail chains including Costco, Walmart and Sam’s Club
• Supplemental testing: Maximum of two (2) tests covered in full within a two (2) year period up to the benefit maximum
• Supplemental aids: 75% of the allowable amount up to the benefit maximum every two (2) years
• Benefit maximum: $1,000 every two (2) years
• Requires pre-authorization