Jump to: Exams, Lenses and Frames | Contact Lenses | Other Services
| 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 - Tier 1 Additional tiers and copayment information found on the NVA website. |
Network — $30 copayment | Non-Network — Not covered | |
| Premium Plan Only Standard progressive multifocal - Tier 1 Additional tiers and copayment information found on the NVA website. |
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 Walmart 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 Walmart or Sam’s Club locations (if included in the network). Discount off remaining balance does not apply at Walmart 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 Walmart or Sam’s Club locations (if included in the network). Discount off remaining balance does not apply at Walmart 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 Walmart or Sam’s Club locations (if included in the network). Discount off remaining balance does not apply at Walmart 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:
|
Non-Network — Not covered | |
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