Standard Plastic Lenses For the following lenses, each covered individual is limited to one set of lenses per calendar year. * On smaller touch enabled devices, use your finger to scroll left or right on the table below. 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 « Previous Page Next Page »
