SELECTED BENEFITS, COPAYMENTS AND ALLOWANCES Sample Clauses

SELECTED BENEFITS, COPAYMENTS AND ALLOWANCES. For a Covered Service received by an Enrollee, Surency will provide the Benefits subject to the amount listed for each benefit which is indicated in the “Summary of Vision Plan Benefits” section, or the amount which is otherwise payable in accordance with the other provisions of this Agreement. Summary of Vision Plan Benefits Group #22596-000-00002-00039 ACCESS E (Declining balance on contact lenses allowance only) MATERIALS COVERED IN NETWORK MEMBER COST OUT OF NETWORK ALLOWANCES FREQUENCY Frames, Lens & Options Package: Any frame, lens and lens options available at provider locations $200 Allowance for frame, lens and lens options 20% off balance over $200 $100 Once every 12 months Contact Lenses: (in-lieu of frames, lens, & options package) Conventional & Disposable Medically Necessary $200 Allowance $0 $100 $200 Once every 12 months Service frequencies are determined by date of service, not calendar year.

SELECTED BENEFITS, COPAYMENTS AND ALLOWANCES. For a Covered Service received by an Enrollee, Surency will provide the Benefits subject to the amount listed for each benefit which is indicated in the “Summary of Vision Plan Benefits” section, or the amount which is otherwise payable in accordance with the other provisions of this Agreement. Summary of Vision Plan Benefits Group # 22596-000-00001-00039 ACCESS A SERVICES IN NETWORK MEMBER COST OUT OF NETWORK ALLOWANCES FREQUENCY Vision Examination with Dilation as Necessary Retinal Imaging $10 Up to $39 $35 N/A Once every 12 months Contact Lens Fit and Follow-Up: (Contact lens fit and two (2) follow-up visits are available once a comprehensive eye exam has been completed.) Standard-spherical clear contact lenses in conventional wear and planned replacement. (Examples include but not limited to disposable, frequent replacement, etc.) $0 $40 Once every 12 months Premium-all lens designs, materials and specialty fittings other than Standard Contact Lenses (Examples include toric, multifocal, etc.) Access Network 10% off retail, then apply $55 allowance $40 Once every 12 months Frames: Any available frame at provider location. $130 Allowance $65 Once every 12 months Standard Plastic Lenses: Single Vision $25 Copay $25 Bifocal $25 Copay $40 Once every 12 months Trifocal $25 Copay $55 Lens Options: Standard Polycarbonate Adults: $40 Dependents under 19: $0 $25 $25 Once every 12 months UV Coating Tint (Solid and Gradient) Standard Scratch-Resistance Standard Anti-Reflective Coating Standard Progressive (Add-on to Bifocal) Premium Progressive Lenticular $15 $15 $15 $45 $65 $65 + 80% off Retail price less $120 $25 Copay Not covered Not covered Not covered Not covered $40 $40 $55 Once every 12 months Once every 12 months Other Add-Ons and Services 20% off Retail Price Not covered Contact Lenses: (Contact lens allowance includes materials only) (Allowance not available if eyeglass lenses are elected) Conventional $130 allowance 15% off balance over $100 Once every 12 months Disposable $130 allowance $100 Medically Necessary $0 $200 Service frequencies are determined by date-of-service, not calendar year.