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Vision Hardware Coverage
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Coverage In-Network Provider Out-of-Network Benefit
Materials Copay $20 N/A
Lenses-One Pair per plan year instead of contact lenses
Plastic or glass  Covered 100% Up to $45
Standard Polycarbonate- Covered for under 18 only Up to $64
Single vision, Bifocal, Trifocal, or Lenticular Up to $80
One every two Plan Years instead of contact lenses
Plan Pays: Up to $130 Plan Pays: Up to $52
Contact lenses
Once every year instead of lenses or lenses and frames
$130 Up to $95
Up to $210
Elective Therapeutic (must meet medically necessary criteria) Covered 100% Up to $210