In-Network Out of Network Exam, Lenses, and Frames Yearly Frequency of Service $0 $0 Deductible per plan year 100% $40.00 Vision Exam Standard Plastic Lenses (Pair): 100% $30.00 Single Vision 100% $50.00 Bifocal 100% $70.00 Trifocal 100% $70.00 Lenticular $55 Copay $52.00 Standard Progressive $85 Copay $52.00 Premium Progressive Tier 1 $95 Copay $52.00 Premium Progressive Tier 2 $110 Copay $52.00 Premium Progressive Tier 3 $175 Copay $52.00 Premium Progressive Tier 4 $45 Copay $5.00 Standard Anti-Reflective $57 Copay $5.00 Premium Anti-Reflective Tier 1 $68 Copay $5.00 Premium Anti-Reflective Tier 2 $85 Copay $5.00 Premium Anti-Reflective Tier 3 Additional Discounts Up to $39 N/A Discounted Retinal Imaging Exam Benefit Contact Lens Fit and Follow-up $40.00 N/A Standard Contact Lens Fit & Follow-up Discounted Lens Options $75.00 N/A Photochromic (Plastic) $15.00 N/A Tint (Solid & Gradient) $15.00 N/A UV Treatment $15.00 N/A Standard Plastic Scratch Coating $40.00 N/A Standard Polycarbonate 20% off Retail Price N/A Other Add-on Services and Materials 40% Discount and a 15% discount on conventional lenses once funded benefit N/A Additional Pairs of Glasses is used. Lasik or PRK form US Laster Network 15% off retail price or 5% off N/A Lasik promotional price. Amplifon Hearing Health Care Network, 40% off hearing exams and a low price N/A Hearing Care guarantee on discounted hearing aids. Journey Health System 2019 Medical Insurance Summary and Review Highmark Community Blue Flex and UPMC Health Plan
In-Network Out of Network Frequency of Service Exam, Lenses, and Frames Yearly Deductible per plan year $0 $0 Vision Exam 100% $40.00 Standard Plastic Lenses (Pair): Single Vision 100% $30.00 Bifocal 100% $50.00 Trifocal 100% $70.00 Lenticular 100% $70.00 Standard Progressive $55 Copay $52.00 Premium Progressive Tier 1 $85 Copay $52.00 Premium Progressive Tier 2 $95 Copay $52.00 Premium Progressive Tier 3 $110 Copay $52.00 Premium Progressive Tier 4 $175 Copay $52.00 Standard Anti-Reflective $45 Copay $5.00 Premium Anti-Reflective Tier 1 $57 Copay $5.00 Premium Anti-Reflective Tier 2 $68 Copay $5.00 Premium Anti-Reflective Tier 3 $85 Copay $5.00 Additional Discounts Discounted Retinal Imaging Exam Benefit Up to $39 N/A Contact Lens Fit and Follow-up Standard Contact Lens Fit & Follow-up $40.00 N/A Discounted Lens Options Photochromic (Plastic) $75.00 N/A Tint (Solid & Gradient) $15.00 N/A UV Treatment $15.00 N/A Standard Plastic Scratch Coating $15.00 N/A Standard Polycarbonate $40.00 N/A Other Add-on Services and Materials 20% off Retail Price N/A Additional Pairs of Glasses 40% Discount and a 15% discount on conventional lenses once funded benefit is used. N/A Lasik Lasik or PRK form US Laster Network 15% off retail price or 5% off promotional price. N/A Hearing Care Amplifon Hearing Health Care Network, 40% off hearing exams and a low price guarantee on discounted hearing aids. N/A Journey Health System 2019 Medical Insurance Summary and Review Highmark Community Blue Flex and UPMC Health Plan
2019PlanHighlights.docx