Cosmetic $51.00 Obtain vision services from provider of your choice. Pay entire cost up front, then submit claim to carrier for reimbursement up to the above allowed amounts. VISION SERVICES - PEDIATRIC Vision Medical 100% of allowed benefit after $15 copay – “sick” visit Vision Routine exam 100% of allowed benefit – Vision Supplies 100% of allowed benefit – Frames/Lenses or Contacts. Limited to dependent children age 18 and under. Medically necessary No deviations will be considered Frames/Lenses or Contacts. Contacts in lieu of Frames/Lenses.
Cosmetic $51.00 Obtain vision services from provider of your choice. Pay entire cost up front, then submit claim to carrier for reimbursement up to the above allowed amounts. VISION SERVICES - PEDIATRIC Vision – Medical “sick” visit 100% of allowed benefit after $15 copay Vision – Routine exam 100% of allowed benefit Vision Supplies – Frames/Lenses or Contacts. 100% of allowed benefit Limited to dependent children age 18 and under. Medically necessary Frames/Lenses or Contacts. Contacts in lieu of Frames/Lenses. No deviations will be considered
SLEOLAMedical_FA2_EPO-SF.docx