PMC 2024 Benefit Guide (English)

VISION — SELECT VISION SERVICE PLAN

IN-NETWORK

OUT-OF-NETWORK

BENEFIT

Eye Exam

$10 copay

Up to $46 reimbursement

Frequency Exam

Once every 12 months Once every 12 months Once every 24 months

Once every 12 months Once every 12 months Once every 24 months

Lenses Frames

Frames

$20 copay; covered up to $120

Up to $47 reimbursement

Lenses Single Vision Lenses Bifocal Vision Lenses Trifocal Vision Lenses Lenticular Vision Lenses

$20 copay $20 copay $20 copay $20 copay

Up to $47 reimbursement Up to $66 reimbursement Up to $85 reimbursement Up to $125 reimbursement

Contacts Elective Medically Necessary

$20 copay; covered up to $120 $20 copay

Up to $120 reimbursement Up to $210 reimbursement

7