VIEW IN-NETWORK BENEFITS FASHION ADVANTAGE …Fashion Selection Covered Covered Covered $20 member...
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IN-NETWORK BENEFITS FREQUENCY - ONCE EVERY: Eye Health Examination inclusive of Dilation (when professionally indicated) Spectacle Lenses Frame Contact Lenses (in lieu of eyeglasses) Every January 1st Every January 1st Every January 1st Every January 1st Every January 1st Every January 1st Every January 1st Every other January 1st Every other January 1st Every other January 1st Every other January 1st Every other January 1st COPAYMENTS Eye Health Examination Covered Contact Lens Evaluation, Fitting & Follow-Up Care Covered Covered Covered EYEGLASS BENEFIT - FRAME (in lieu of contact lenses) Non-Collection Frame Allowance (Retail) Up to $60 allowance Up to $100 allowance The Exclusive Collection /2 /3 /1 (in lieu of allowance): Fashion Selection Covered Covered Covered $20 member charge $40 member charge $20 member charge $40 member charge Designer Selection Premier Selection EYEGLASS BENEFIT - SPECTACLE LENSES MEMBER CHARGES Plastic or glass single vision, bifocal or trifocal lens in any size or Rx Covered Covered Covered $15 Post-cataract Lenses Glass-Grey #3 Prescription Sunglasses Tinting of Plastic Lenses - Solid / Gradient Scratch-Resistant Coating Blended Segment Lenses Polycarbonate Lenses (Children / Adults) $15 $15 $15 Ultraviolet Coating Anti-Reflective Coating (Standard / Premium) $20 $20 $20 $20 Intermediate Vision Lenses $30 $30 $15 $0 / $35 $0 / $35 $15 $40 / $55 $40 / $55 $70 $70 $20 $20 Plastic Photosensitive Lenses Glass Photochromic Lenses CARNEGIE MELLON BENEFIT OVERVIEW Members Under 19 Members 19 and Over FASHION ADVANTAGE OPTION I OPTION II FASHION ADVANTAGE GOLD
Transcript of VIEW IN-NETWORK BENEFITS FASHION ADVANTAGE …Fashion Selection Covered Covered Covered $20 member...
IN-NETWORK BENEFITS
FREQUENCY - ONCE EVERY:
Eye Health Examination inclusive of Dilation(when professionally indicated)
Spectacle Lenses
Frame
Contact Lenses (in lieu of eyeglasses)
Every January 1st
Every January 1st
Every January 1st
Every January 1st
Every January 1st
Every January 1st
Every January 1st
Every other January 1st
Every other January 1st
Every other January 1st
Every other January 1st
Every other January 1st
COPAYMENTS
Eye Health Examination Covered
Contact Lens Evaluation, Fitting & Follow-Up Care
Covered
Covered Covered
EYEGLASS BENEFIT - FRAME (in lieu of contact lenses)
Non-Collection Frame Allowance (Retail) Up to $60 allowance Up to $100 allowance
The Exclusive Collection /2
/3
/1
(in lieu of allowance):
Fashion Selection Covered
Covered
Covered
$20 member charge
$40 member charge
$20 member charge
$40 member charge
Designer Selection
Premier Selection
EYEGLASS BENEFIT - SPECTACLE LENSES MEMBER CHARGES
Plastic or glass single vision, bifocal or trifocal lens in any size or Rx Covered
Covered Covered
$15
Post-cataract Lenses
Glass-Grey #3 Prescription Sunglasses
Tinting of Plastic Lenses - Solid / Gradient
Scratch-Resistant Coating
Blended Segment Lenses
Polycarbonate Lenses (Children / Adults)
$15
$15$15
Ultraviolet Coating
Anti-Reflective Coating (Standard / Premium)
$20 $20
$20 $20
Intermediate Vision Lenses $30 $30
$15
$0 / $35$0 / $35
$15
$40 / $55 $40 / $55
$70 $70
$20 $20
Plastic Photosensitive Lenses
Glass Photochromic Lenses
CARNEGIE MELLON BENEFIT OVERVIEW
MembersUnder 19
Members 19and Over
FASHION ADVANTAGEOPTION I OPTION II
FASHION ADVANTAGE GOLD
IN-NETWORK BENEFITS
OUT-OF-NETWORK SERVICE
EYEGLASS BENEFIT - SPECTACLE LENSES (continued) MEMBER CHARGES
$60
$75
$40
$64
$30
$40
$60
$80
Bifocal Lenses
Frame
Eye Examination $32
$30
Single Vision Lenses
Trifocal Lenses
Lenticular Lenses
Standard PALs
Conventional Contact Lenses
Disposable Contact Lenses
Contact Lens Evaluation & Fitting (Daily Wear)
Contact Lens Evaluation & Fitting (Extended Wear)
Visually Required Contact Lenses (with prior approval) $225
$36
$46
$72
N/A $130
$48
$20
$30
$80
$35
$35
$75 $120
$25
$225
Progressive Lenses (Standard / Premium / Ultra) $65 / $105 / $140 Covered / $40 / $90
$75
$60High-Index Lenses
Polarized Lenses
CONTACT LENS BENEFIT
Non-Collection Contact Lenses:
Disposable / Non-Disposable LensesStandard Hard Daily-Wear LensesSpecialty Lenses
Exclusive Collection of Contact Lenses:
Standard, Hard, Daily Wear(Includes evaluation, fitting and follow-up)
One pair of lenses One pair of lenses
Up to $75 AllowanceCovered
---Covered
Up to $110 Allowance
Up to $120 Allowance
(in lieu of eyeglasses)
Visually Required Contact Lenses (with prior approval) - Materials, Evaluation, Fitting & Follow-up Care
Covered Covered
2/Exclusive Collection is available at most participating provider offices. Collection is subject to change. All contact lenses in the Collection are single-vision spherical lenses.
1/When Davis Vision Exclusive Collection Contact Lenses are prescribed.
3/Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with presciptions +/- 6.00 diopters or greater.
4/ Can be applied toward disposable or specialty contact lenses (including extended wear, hard/soft bifocal and gas permeable lenses).5/ Including but not limited to hard/soft daily wear, bifocal, toric and gas permeable.
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CARNEGIE MELLON BENEFIT OVERVIEW (CONTINUED)
OUT-OF-NETWORK REIMBURSEMENT - UP TO:
CMU_122016
/4 /5
/2
FASHION ADVANTAGEOPTION I OPTION II
FASHION ADVANTAGE GOLD
FASHION ADVANTAGEOPTION I OPTION II
FASHION ADVANTAGE GOLD
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