Common use of Out of Network Clause in Contracts

Out of Network. Examination – once a calendar year Covered 100% (after $6.50 co-pay) Optometrist reimbursed up to $28.50 Ophthalmologist reimbursed up to $38.50 Frames – once a calendar year Up to $65 retail Reimbursed up to $44 Lenses – once a calendar year Single Bi-focal Tri-focal Lenticular Lenses / photogrey & transition / polarized / tints Covered 100% after $18 co-pay Covered 100% after $18 co-pay Covered 100% after $18 co-pay Covered 100% after $18 co-pay Lenses / photogrey & transition / polarized / tints $29 / $18 / $4 reimbursement $51 / $30 / $10 reimbursement $63 / $38 / $12 reimbursement $75 / $44 / $14 reimbursement Elective Contact Lenses (in lieu of lens/frame) – once a calendar year Medically necessary (Prior authorization is required): Up to $90 Covered 100% Reimbursed up to $90 Reimbursed up to $175