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BENEFITS NETWORK NON-NETWORK
Exams — once every calendar year — two annual exams covered for children up to age 18 Exams — once every calendar year — two annual exams covered for children up to age 18
Vision Exam Network — $10 copayment Non-Network — Reimbursed up to $45
Lenses — once every calendar year; copayment applied to all lens options Lenses — once every calendar year; copayment applied to all lens options
Single-vision lenses (per pair) Network — $25 copayment Non-Network — Reimbursed up to $30
Bifocal lenses (per pair) Network — $25 copayment Non-Network — Reimbursed up to $50
Trifocal lenses (per pair) Network — $25 copayment Non-Network — Reimbursed up to $65
Lenticular lenses (per pair) Network — $25 copayment Non-Network — Reimbursed up to $100
Polycarbonate lenses (per pair)
Applies to children up to age 18
Network — 100% coverage Non-Network — Not covered
Premium Plan Only
Standard anti-reflective coating
Network — $30 copayment Non-Network — Not covered
Premium Plan Only
Standard progressive multifocal
Network — $50 copayment Non-Network — Not covered
Frames — once every two calendar years; once every calendar year for children up to age 18 Frames1 — once every two calendar years; once every calendar year for children up to age 18
Frames1 Basic Plan
Network — Up to $125 retail allowance and 20% discount off remaining balance

Up to $55 Every Day Low Price price point at Wal-Mart or Sam’s Club locations (if included in the network). Discount off remaining balance does not apply at Wal-mart or Sam’s Club locations.
Non-Network — Reimbursed up to $70
Premium Plan
Network — Up to $175 retail allowance and 20% discount off remaining balance

Up to $77 Every Day Low Price price point at Wal-Mart or Sam’s Club locations (if included in the network). Discount off remaining balance does not apply at Wal-mart or Sam’s Club locations.
Non-Network — Reimbursed up to $70

Contact Lenses — once every calendar year in place of eye glass lenses Contact Lenses — once every calendar year in place of eye glass lenses
Elective 1
If member prefers contacts to glasses

Retail allowances may be used over multiple visits in the same calendar year.
Basic Plan
Network — Up to $125 retail allowance and 15% discount off conventional or 10% discount off disposable remaining balance

Up to $92 Every Day Low Price price point for contact lenses at Wal-Mart or Sam’s Club locations (if included in the network). Discount off remaining balance does not apply at Wal-mart or Sam’s Club locations.
Non-Network — Contact lenses reimbursed up to $105
Premium Plan
Network — Up to $175 retail allowance and 15% discount off conventional or 10% discount off disposable remaining balance

Up to $129 Every Day Low Price price point for contact lenses at Wal-Mart or Sam’s Club locations (if included in the network). Discount off remaining balance does not apply at Wal-mart or Sam’s Club locations.
Non-Network — Contact lenses reimbursed up to $105
Necessary
If medically necessary with prior approval from National Vision Administrators, L.L.C. (NVA)
Network — Additional costs covered at 100% Non-Network — Contact lenses reimbursed up to $210
Fitting and Evaluation Network — $20 copayment for daily contact lenses;
$30 copayment for extended contact lenses;
$50 copayment for specialty contact lenses
Non-Network — Reimbursed up to $20 for daily contact lenses; Reimbursed up to $30 for extended or specialty contact lenses

Other Other
Optional Items (cosmetic extras) Network — Discount applied to all lens options Non-Network — Not covered
EyeEssential Discount Plan Network — When members exhaust their annual benefits, NVA offers the EyeEssential Discount Plan, which provides significant discounts on materials through participating NVA network providers. Non-Network — Not covered
LASIK Discounts Network — NVA members will pay a maximum amount for corrective laser surgery:
  • Traditional PRK – $1,500 per eye
  • Traditional LASIK – $1,800 per eye
  • Custom LASIK – $2,300 per eye
Members may receive additional benefits at LasikPlus locations nationwide:
  • Special pricing on select technologies
  • Free initial consultation and comprehensive LASIK vision exam
  • Advanced laser technologies including Wavefront and IntraLase (All-Laser LASIK)
  • Financing options available
Non-Network — Not covered
  1. Wal-Mart and Sam’s Club Example: A member with the Premium Plan chooses a pair of frames at Wal-Mart that cost $128. The Premium Plan pays $77, and the member pays the $51 difference.

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