| Service | In-Network Cost | Out-Of-Network Reimbursement |
| Exam with Dilation as Necessary (once per calendar year) |
$0 copay | Up to $48 |
| Retinal Imaging | Up to $25 | Not eligible |
| Frames (once every calendar year) | $0 copay; $150 allowance 20% off balance over $150 |
Up to $64 |
| Standard Plastic Lenses (once every calendar year; in lieu of contact lenses) | ||
| Single Vision | $0 copay | Up to $36 |
| Bifocal | $0 copay | Up to $54 |
| Trifocal | $0 copay | Up to $69 |
| Lenticular | $0 copay | Up to $85 |
| Standard Progressive Lens | $55 copay | Up to $54 |
| Premium Progressive Lens | 20% off retail less $65 allowance | Up to $54 |
| Contact Lens Fit and Follow-Up | ||
| Standard | $40 allowance; covers fit and two follow-up visits | Not Eligible |
| Premium | $10 off retail price for premium | |
| Contact Lenses (once every calendar year; in lieu of lenses for glasses) | ||
| Conventional | $0 copay, $150 allowance, 15% off balance over $130 | Up to $105 |
| Disposable | $0 copay, $150 allowance | Up to $105 |
| Medically Necessary | $0 copay, paid-in-full | Up to $210 |