Exam Benefit:
Member receives one routine vision exam every 12 months based upon contract date. Exam copay is $10.

Materials Benefit:
The member has a $175 retail frame allowance which renews every 24 months, based on contract date and a paid-in-full standard (plastic) lens allowance which renews every 12 months, based on contract date. There is a $10 materials co-pay.  In lieu of glasses the member may use his/her material benefit for a $125 contact lens allowance, which renews every 12 months.  The contact lens benefit may be used for fitting, follow-up and /or contact lenses.  Members also receive a discount of 20% from any balance remaining after the frame allowance is exceeded.  If the member chooses to purchase lens upgrades, the maximum liabilities listed on this page are paid by the member at the time of purchase.  Members also receive 2nd pair discounts of 30% off frames, 25% off sunglasses & 20% off contacts for additional pairs of eyeglasses and contacts when not prohibited by manufacturer.  In network providers submit claims to OptiCare.

For out-of-network services, the member is responsible for all charges on the date of visit but can submit an out-of-network form with an itemized receipt to OptiCare and receive up to $38.50 for examinations, up to $122.50 for frames, up to $87.50 for contact lenses, and between $37.50 and $90.00 for ophthalmic lenses (co-pays apply).

Member Maximum Ophthalmic Lens Add-On Liabilities (per pair)
Polycarbonate (V2784)	$ 35.00		Photochromatic / Transition (V2744)	$ 40.00
UV Treatment (V2755)	$ 15.00		Scratch Resistance (V2760)	$ 15.00
Progressive Lens (V2781)	$ 85.00		Anti-Reflective Treatment (V2750)	$ 40.00
High Index (V2782, V2783)	$ 50.00		Tint (Solid or Gradient) (V2745)	$ 15.00
80% of Usual and Customary for miscellaneous add-ons. Add-ons should be reported as listed above, in addition to the underlying lens code.

Notes: