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In-Network <br />Vision Services Medicare -Covered Vision Services <br />■ $45 copay for specialist to <br />diagnose and treat eye diseases <br />and conditions <br />■ $0 copay for glaucoma screening <br />(once per year for members at <br />high risk of glaucoma) <br />• $0 copay for one diabetic retinal <br />exam per year <br />• $0 copay for one pair of <br />eyeglasses or contact lenses after <br />each cataract surgery <br />Additional Vision Services <br />In -Network <br />■ $0 copay for an annual routine eye <br />examination 1 every 12 months. <br />■ $0 copay for lenses, frames or <br />contacts. Member responsible for <br />any amount in excess of annual <br />maximum plan benefit allowance. <br />• $250 maximum allowance per <br />year towards the purchase of <br />lenses, frames or contacts. <br />Out -of -Network <br />• Member pays up front and is <br />reimbursed 50% of <br />non -participating rates for <br />covered comprehensive dental <br />services. <br />Medicare -Covered Vision Services <br />■ 40% of the Medicare -allowed <br />amount for glaucoma screening <br />■ 40% of the Medicare -allowed <br />amount after $2,000 <br />out -of -network deductible for <br />Medicare -covered specialist <br />services to diagnose and treat <br />diseases and conditions of the eye <br />and diabetic retinal exams <br />• 40% of the Medicare -allowed <br />amount after $2,000 <br />out -of -network deductible for <br />eyeglasses or contact lenses after <br />cataract surgery <br />Additional Vision Services <br />Out -of -Network <br />• Member must pay 100% of the <br />charges and submit the <br />itemized receipt(s) for <br />reimbursement of 50% of the <br />in -network allowed amount for <br />an annual routine eye examination <br />1 every 12 months. <br />