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LGHP Vision Benefit Schedule 

 

Vision coverage is provided at no additional cost to members enrolled in any of the LGHP health plans. All members and enrolled dependents have the same vision coverage regardless of the health plan selected. All vision benefits are available once every 24 months from the last date used. Copayments are required.

  Service

 Network Provider Benefit

 Out-of-Network Provider Benefit*

Eye Exam

$10 copayment 

$20 allowance 

Spectacle Lenses*
(single, bifocal and trifocal)

 $10 copayment

 $20 allowance for single vision lenses
$30 allowance for bifocal and trifocal lenses

Standard Frames

 $10 copayment
(up to $90 retail frame cost; member responsible for balance over $90)

 $20 allowance

Contact Lenses
(all contact lenses are in lieu of spectacle lenses)

 $20 copayment for medically necessary
$50 copayment for elective contact lenses
$70 allowance for all other lenses not mentioned above

 $70 allowance

 * Spectacle Lenses: Plan participant pays any and all optional lens enhancement charges. Network providers may offer additional discounts on lens enhancements and multiple pair purchases.

** Out-of-network claims must be filed within one year from the date of service.