burpee_guide

PLAN NAME

BENEFIT

IN-NETWORK

OUT-OF-NETWORK

Eye Exam

$00 copay

$00

Hardware (Frames and Lenses)

$00 copay

$00

Frequency Exam

$00 $00 $00

$00 $00 $00

Lenses Frames

Frames

$00

$00

Lenses Single Vision Lenses Bifocal Vision Lenses Trifocal Vision Lenses

$00 $00 $00

$00 $00 $00

Medically Necessary/Elective Contact Lenses

$00

$00

Bi-Weekly Contributions Employee Only Employee + Spouse Employee + Child(ren) Employee + Family

$00 $00 $00 $00

$00 $00 $00 $00

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