VOXX 2024 OE Guide - FINAL

BENEFIT

IN-NETWORK

OUT-OF-NETWORK

Eye Exam

$10 copay

Up to $30 reimbursement

Frequency Exam

12 months 12 months 12 months

12 months 12 months 12 months

Lenses Frames

Frames

$130 allowance towards any frame plus 20% off balance; OR Any fashion or designer level from Davis Vision’s Collection (retail value, up to $160)

Up to $30 reimbursement

Lenses Single Vision

$25 copay $25 copay $25 copay $25 copay

Up to $25 reimbursement Up to $35 reimbursement Up to $45 reimbursement Up to $60 reimbursement

Bifocals Trifocals Lenticular

Contact Lens Evaluation, Fitting & Follow Up* Davis Vision Collection Standard, soft contacts Specialty Contacts

Covered in full after $25 copay Covered in full after $25 copay $60 allowance plus 15% off balance (limitations may apply) Covered in full with prior approval/ $130 allowance plus 15% off balance

Up to $30 reimbursement

Medically Necessary/ Elective Contact Lenses

Up to $225 reimbursement/ Up to $75 reimbursement

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