Page 15 - Caltech

Eyeglass lenses/lens options (continued)
In network
Out of network
You pay discounted fee of $15
Not covered
You pay discounted fee of $40
Not covered
You pay discounted fee of $40
Not covered
You pay discounted fee of $45
Not covered
You pay 80% of retail
Not covered
You pay 80% of retail
Not covered
Standard plastic scratch coating
Standard polycarbonate lenses — adult
Standard polycarbonate lenses — children to age 19
Standard anti-reflective coating Photochromic/transitions plastic Polarized
Contact lenses
In network
Out of network
Use your contact lens coverage once every calendar year to purchase either one pair of eyeglass lenses or one order of contact lenses.
Conventional contact lenses
Disposable contact lenses Medically necessary contact lenses
*Allowances are one-time use benefits. No remaining balances may be used. The plan does not provide a declining balance benefit.
$115 allowance* Additional 15% off balance over the allowance
$80 reimbursement
$115 allowance*
$80 reimbursement
$0 copay
$200 reimbursement
Frames In network
Use your frame coverage once every calendar year.
Any frame available, including frames for prescription sunglasses
Discounts In network
Out of network
Out of network
$130 allowance
Additional 20% off balance over the allowance
$65 reimbursement
Discounts cannot be combined with any other discounts or promotional offers and may not be available on all brands.
Additional pairs of eyeglasses or prescription sunglasses — discount applies to purchases made after the plan allowances have been exhausted
Non-covered items such as cleaning cloths and contact lens solution
Lasik laser vision correction
or photorefractive keratectomy (PRK) from U.S. Laser Network only — call 1-800-422-6600
Retinal imaging Replacement contact lenses
Up to a 40% discount
No discount
20% discount
No discount
15% discount off retail or 5% discount off the promotional price
No discount
You pay a discounted fee up to $39
No discount
Receive significant savings after your lens benefit has been exhausted on replacement contacts by ordering online — visit http://www.aetnavision.com
for details
No discount
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