What the Plan Provides
Exams
For the following exams, each covered individual is limited to one service per calendar year.
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Care and Service
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In-Network Cost
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Non-Network Reimbursement
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WellVision Exam®
A complete initial vision analysis, which includes a comprehensive visual exam, including the prescription for corrective eyewear and dilation, if necessary
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$0 copayment
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Reimbursed up to $45
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Retinal Imaging Screening
An enhancement to the WellVision Exam®.
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Up to $39 copayment
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No coverage
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Standard Contact Lens Fit & Follow-Up Exam*
Fitting and evaluation
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Copayment of up to $40
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No coverage
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Premium Contact Lens Fit & Follow-Up*
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Copayment of up to $55
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No coverage
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* One Contact Fit/Follow-Up benefit per calendar year (either standard or premium).
