What is covered
EyeMed Insight network benefit
Out-of-network
reimbursement
None
None
Exam with dilation as necessary
$15 copay
(twice/year for children)
$45
Deductible
Retinal imaging copay
$39 copay
Not covered
Frames/lenses copay
$0 copay; $150 allowance,
20% off balance over $150
See below for lens option
$70
See below for lens options
Lenses benefit frequency – based on calendary year
12 months
12 months
Frames benefit frequency – based on calendary year
24 month (adult)
12 months for child
24 month (adult)
12 months for child
Eyeglasses
Single vision
$25 copay
$30
Bifocal
$25 copay
$50
Trifocal
$25 copay
$65
Lenticular
$25 copay
$100
Lens Upgrades
Polycarbonate lenses
$35 copay (adult)
$0 copay for child
Not covered
Ultraviolet (UV) coating
$0 copay
$9
Scratch protection plan
$0 copay
$9
Anti-reflective coating
$45-85 copay
Not covered
Tinting of plastic lenses
$15 copay
Not covered
High-index lenses
20% off retail
Not covered
Progressive lenses
Standard: $0 copay
Premium: $95-$200 copay
$50
Photosensitive lenses
$33 copay
Not covered
Polarized lenses
20% off retail price
Not covered
Other add-ons
20% off retail price
Not covered
Contact Lenses – covered only in lieu of eyeglasses lenses
Conventional contacts
$0 copay; $150 allowance;
15% off a balance over $150
$105
Disposable contacts
$0 copay; $150 allowance
$105
Medically necessary contacts
$0 copay; paid in full
$210
Contact lens fit and follow-up
Standard: Up to $40 copay
Premium: 10% off retail price
Not covered
Mail order replacement option
No*
No