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Starts 10/1/23 thru 1/31/24

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Open Enrollment 2024

Open Enrollment 2022

SCHEDULE OF EXTRAS
EYEGLASSES                                                    Single Vision          Multifocal
Gradient Tint (Plastic)                                                 $15                     $15
Double Gradient Tint (Plastic)                                    $12                     $22
Photochromatic (Glass) $50 $65
Photochromatic (Plastic) Transitions $80 $95
Solid Tint (Plastic)
(Other than #1 Tint) $15 $15
Solid Tint (Glass) $20 $20
Polish Edges (Plastic) $20 $20
Polaroid $60 $105
AR-cote $42 $42
All Other Coatings $42 $42
Scratch Resistant (Plastic) $22 $22
Hi-index (1.56) $45 $60
Polycarbonate $45 $60
Slab-Off $60 $60
Oversize (66mm ED)
(Where applicable) $15 $20
UV-400 $15 $15
Facette $50 $65
B/F 35mm-Exec.   $45
T/F 28mm   $40
T/F 35mm-Exec.   $65
Progressive (Generic) (Plastic)
(i.e. Sola, XL or VIP)   $115
Progressive (photox) (Generic)   $155
Blended   $70
Remove Tint (retint) $20 $20
High Magnification:    
+/- 6.25D - +/- 8.00D (per lens) $18 $22
+/- 8.25D - +/- 11.00D (per lens) $30 $36
Over +/- 11.00D (per .5D per lens) $4 $6
Adds +3.25 - 4.00D (per lens)   $14
Cylinder +/- 3.25D or more
(per lens) $14 $18
Prism (per D, per lens) $8 $8
if patient/member desires, 2nd set of lenses/frames or both regular fees apply

REPAIRS:    
Soldering $19
Emergency repairs and/or replacement of lenses and/or frames. (Does not include the charges for the lenses or the frames.) The subscriber or member is responsible for the fee for service charges for the new frames and/or lenses. No Charge

CONTACT LENSES: EACH 24 MONTHS
(if desired in addition to Basic Benefit) C.L. examination and evaluation, including 3 months follow-up visits (if required) and including: K measurements, fitting by K reading or trial lens method and subsequent prescription. If clinically appropriate, verifying accuracy of the lenses, silk lamp evaluation of the cornea and the contact lens, dispensing the lenses with instructions for the proper use, handling and cleaning of the lenses.
$50 Co-Pay
(Other than toric and multifocal)
Toric and Multifocal $75 Co-Pay
Each Additional Visit (after 3 mons.) $15
Contact Lens Service Agreement By Doctor

LENS TYPE: (per pair) EACH 24 MONTHS
Extended Sphericals CO-PAY
Bausch & Lomb (03, 04) $60
American Hydron (Zero 4) $75
Hydracurve (Softmate II) $179
CSI 'T' $190
Ocular Science $65

Extended Toric:    
Hydracurve (II Series) $236
D3 x 4 $236

Daily Spherical:    
American Hydron $60
Bausch & Lomb $60
CIBA $60

Daily Toric:    
CIBA (Torisoft) $153
Bausch & Lomb $153

Gas Permeable:
Permaflex 258 $110
Optacryl 60 $110
Polycon $110
Hard Lens (regular-per lens) $49
Hard Lens (clean & polish, per lens) $15
Opaque -20% U.C.R.
Disposables (1st 3 mos. only) -20% U.C.R.
Contact lens powers over +8.00 D SPH and/or +1.50 D CYL are considered custom, and will be charged extra.

Have more questions>  Call Toll Free (800) 400-4872

Health insurance Plans

Provider Directory   -   Schedule of Extras   -   B1 Online Brochure
B1 Online Application (Hard Copy)     -   Contact Lens Info

For more details visit:   www.VisionPlanofAmerica.com

Vision Plan of America
Schedule of Extras

Have Questions?  Call (800) 400-4872

VISION EXTRAS