Common use of Out of Network Clause in Contracts

Out of Network. Examination – once a calendar year Covered 100% Optometrist reimbursed up to $35 Ophthalmologist reimbursed up to $45 Frames – once a calendar year Up to $65 retail Reimbursed up to $55 Lens – once a calendar year Single Bi-focal Tri-focal Lenticular Covered 100% Covered 100% Covered 100% Covered 100% Clear/ Photogrey or Transition / Polarized / Tints & Coats/ $38 / NA / $18 / $4 reimbursement $60/ NA / $30 / $10 reimbursement $72/ NA / $38 / $12 reimbursement $108/ NA / $30 / $10 reimbursement Contact Lens (in lieu of lens/frame) – once a calendar year Elective Medically necessary (prior authorization is required): Up to $115 Covered 100% Reimbursed up to $115 Reimbursed up to $200