VISION

Guardian	Network Providers	Non-Network Providers
Routine Eye Exam (Annual)	$10 copay	$50 max before copay
Eyeglass Frames (Every 24 months)	$130 allowance + 20% off balance	$48 max
Eyeglass Lenses (Annual)	Instead of contacts – Once every calendar year
Single Lenses	$0	$48 max
Bifocal Lenses	$0	$67 max
Trifocal Lenses	$0	$86 max
Contact Lenses Elective conventional	$130 max + 15% off balance (copay waived)	$105 max (copay waived)
Contact Lenses Non-elective (Medically necessary)	$0	$210 max (copay waived)