PLATINUM 150

$10 Exam and $10 Eyewear co-payments

In Network Out of Network

Vision exam: Paid if full after co-pay Up to $35.00

Frame: Up to $150.00 after co-pay Up to $55.00

Lenses

Single Vision (pr) Paid in full Up to $25.00

Bifocal (pr) Paid in full Up to $40.00

Trifocal (pr) Paid in full Up to $45.00

Lenticular Paid in full Up to $80.00

Contact Lenses

Elective Up to $150.00 Up to $65.00

Medically required Paid in full Up to $150.00

Laser Vision Correction $250.00 in or out of network

MONTHLY RATES

EE $8.11

EE+1 $13.80

EE/F $20.30