| Covered Services |
Participating Provider |
Non-Participating Provider |
| Examinations |
Limited to one examination per benefit period. |
Covered in full, less any deductible. |
Plan pays up to $28.00 less any deductible. |
| Frames |
Limited to one frame per benefit period. |
Plan pays up to $100.00 less any deductible. You will receive the DeltaVision discount on the retail price of frames before the DeltaVision payment. |
Plan pays up to $55.00 less any deductible. |
| Lenses (per lens) |
Limited to one set of lenses per benefit period. |
| Single Vision |
Covered in full, less any deductible. |
Plan pays up to $15.00 less any deductible. |
| Bifocal |
Plan pays up to $22.50 less any deductible. |
| Trifocal |
Plan pays up to $25.00 less any deductible. |
| Progressive |
Plan pays up to $42.50 less any deductible. The DeltaVision discount applies. |
Plan pays up to $25.00 less any deductible. |
| Polycarbonate (for children up to age 18) |
Plan pays up to $10.00 less any deductible. The DeltaVision discount applies. |
Plan pays up to $7.50 less any deductible. |
| Other lens options |
No coverage, however you will receive the DeltaVision discount. |
No coverage. |
| Contact Lenses |
Limited to once per benefit period in place of regular lenses. You will receive the lowest price offered by a participating provider. |
| Elective |
Plan pays up to $105.00 |
Plan pays up to $105.00 |
| Medically necessary |
Covered in full. |
Plan pays up to $210.00 |
| Laser Vision Correction |
Limited to once per eye per lifetime |
Plan pays up to $250.00 per benefit period. You will receive the loest price offered by a participating provicer, not to exceed $1,495.00 per eye. |
No coverage. |
Warning: I am able to write to the configuration file: /home/content/u/m/f/umfscua/html/includes/configure.php. This is a potential security risk - please set the right user permissions on this file.
