SPECTERA VISION PLAN

1
SPECTERA VISION PLAN

• In Network Out of Network
• CoPay Exam 10 N/A
• CoPay Materials 20 N/A
• Eye Exam 100 after CoPay Up to 40
• Spectacle Lenses
• Single Vision 100 after CoPay Up to 40
• Bifocal (lined) 100 after CoPay Up to 60
• Trifocal (lined) 100 after CoPay Up to 80
• Frame Allowance 100 up to 50 Up to 45
  wholesale. Amounts retail
• above pay difference

2
SPECTERA VISION PLAN

• In-Network Out of Network
• Contact Lenses
• (elective- fitting, f/u lenses)
• Covered in full 100 Up to 125
• All over elective Up to 125 Up to 125
• Contact Lenses 100 after CoPay Up to 210
• (Medically Necessary)
• LASIK A preferred rate N/A
• 1500 per eye for PRK
• 1800 for LASIK

3
SPECTERA VISION PLAN

• Service Frequency
• Exam- 12 months
• Lenses- 12 months
• Frames- 24 months
• Rate
• Employee 7.06
• Employee Child 14.24
• Employee Spouse 13.58
• Family 21.62
• Network includes WalMart optical, Pearle Vision,
  and
• other providers _at_ https//www.spectera.com/vis
  ion Click future member