Plan Details
Plan Name	Premium $20/$20 Plan
Effective Dates	Jan 01, 2025 to Jan 01, 2026
Benefits	In-Network	Out-of-Network
Exam Copay	$20	$45 up to
Materials Copay	$20	Based on fee schedule
Exam Frequency	12 months	12 months
Lenses Frequency	12 months	12 months
Frames Frequency	24 months	24 months
Contacts Frequency	12 months	12 months
Single Vision Lens	$20 copay	$30 up to
Medically Necessary Contacts	-	-
Elective Contacts	$200 allowance; copay does not apply	$105 up to
Frames	$200 allowance for frame; $250 featured frame brands allowance; 20% savings on the amount over your allowance; $110 Walmart/Sam's Club/Costco frame allowance	$70 up to
Corrective Vision Services (e.g. Laser Surgery)	Discount Available	No Discounts
Second Pair of Glasses	Discount Available	No Discounts