Residential Crisis 100% of allowed 80% of allowed Services benefit benefit after deductible VISION SERVICES - ADULT Vision - Medical 100% after $15 80% of allowed (services related to the copay (PCP) or $25 benefit after medical health of the copay (specialist) deductible eye) Vision - Routine Exam 100% after $15 80% of allowed (per year) copay (PCP) or $25 benefit copay (specialist) deductible Prescription Lenses, Single Vision $29.00 frames and/or contacts. Bifocal, single $49.00 One pair per plan year. Bifocal, $89.00 Frames/lenses or double contacts, not both. Plan Prescription Trifocal $71.00 pays up to noted Lenses Aphakic, glass $54.00 allowed amounts, Aphakic, $126.00 remainder is participant plastic responsibility. Aphakic, $162.00 aspheric Frames $45.00 Medically $202.00 Contacts Necessary 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 80% of allowed – “sick” visit benefit $15 benefit copay deductible Vision Routine exam 100% of allowed 100% of allowed – benefit benefit (member may still be balance billed) Vision Supplies 100% of allowed 80% of allowed – Frames/Lenses or benefit benefit after Contacts. deductible 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.
Residential Crisis Services 100% of allowed benefit 80% of allowed benefit after deductible VISION SERVICES - ADULT Vision - Medical (services related to the medical health of the eye) 100% after $15 copay (PCP) or $25 copay (specialist) 80% of allowed benefit after deductible Vision - Routine Exam (per year) 100% after $15 copay (PCP) or $25 copay (specialist) 80% of allowed benefit deductible Prescription Lenses, frames and/or contacts. One pair per plan year. Frames/lenses or contacts, not both. Plan pays up to noted allowed amounts, remainder is participant responsibility. Prescription Lenses Single Vision $29.00 Bifocal, single $49.00 Bifocal, double $89.00 Trifocal $71.00 Aphakic, glass $54.00 Aphakic, plastic $126.00 Aphakic, aspheric $162.00 Frames $45.00 Contacts Medically Necessary $202.00 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 $15 copay 80% of allowed benefit deductible Vision – Routine exam 100% of allowed benefit 100% of allowed benefit (member may still be balance billed) Vision Supplies – Frames/Lenses or Contacts. 100% of allowed benefit 80% of allowed benefit after deductible 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_FA3_POS-SF.docx