Standard Plastic Lenses

For the following lenses, each covered individual is limited to one set of lenses per calendar year.


Care and Service	In-Network Cost	Non-Network Reimbursement
Standard Plastic Single Vision Lenses Lenses having one part that corrects for either near vision or distant vision	$10 copayment	Reimbursed up to $35
Standard Plastic Lined Bifocal Lenses Lined lenses having one part that corrects for near vision, one for distant vision	$10 copayment	Reimbursed up to $50
Standard Plastic Lined Trifocal Lenses Lined lenses having one part that corrects for near vision, one for intermediate vision, and one for distant vision	$10 copayment	Reimbursed up to $65
Standard Plastic Lenticular Lenses Lenses used to assist post-cataract surgery	$10 copayment	Reimbursed up to $100
Lens Options
Standard Progressive Lenses	$65	Reimbursed up to $50
Premium Progressive Lenses	$95-$185	Reimbursed up to $50
Standard Polycarbonate Lenses	$0 copayment	Reimbursed up to $21
Tints (Solid or Gradient)	$0 copayment	Reimbursed up to $11
Standard Plastic Scratch Coating	$0 copayment	Reimbursed up to $11
UV Coating	$15 copayment	No coverage
Standard Anti-Reflective Coating	$45 copayment	Reimbursed up to $5
Premium Anti-Reflective Coating	$57-$85 copayment	Reimbursed up to $5