Plan Details
Plan Name	Premium Plan
Effective Dates	Jan 01, 2026 to Jan 01, 2029
Benefits	In-Network	Out-of-Network
Exam Copay	$20	$45 up to
Exam Frequency	12 months	12 months
Materials Copay	$20	Based on fee schedule
Single Vision Lens	$20 copay	$30 up to
Lenses Frequency	12 months	12 months
Elective Contacts	$200 allowance; copay does not apply	$105 up to
Medically Necessary Contacts	-	-
Contacts Frequency	12 months	12 months
Frames	$200 allowance for frame; $250 Featured Frame Brands allowance; $250 Visionworks frame allowance on any frame; 20% savings on the amount over your allowance; $110 Walmart/Sam's Club/Costco frame allowance	$70 up to
Frames Frequency	24 months	24 months
Corrective Vision Services (e.g. Laser Surgery)	Discount Available	No Discounts
Second Pair of Glasses	Discount Available	No Discounts