Covered services

Children- under age 19

Adults- age 19 and over

Covered services

¹All other brand names, product names, or trademarks belong to their respective holders.

²Discounts are not insurance and create no liability for payment by the plan.

^{^}You are responsible for frame costs over the allowance, minus a 30 percent discount. The scheduled amounts shown are the maximum allowable amounts. There is no assurance that the scheduled amount will be sufficient to pay the full cost of the service rendered or the materials selected.

^*You are responsible for contact lens costs over the allowance, minus a 25 percent discount. The scheduled amounts shown are the maximum allowable amounts. There is no assurance that the scheduled amount will be sufficient to pay the full cost of the service rendered or the materials selected.