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BENEFITS NETWORK NON-NETWORK
Exams — once every calendar year — two annual exams covered for children up to age 18 Exams — once every calendar year — two annual exams covered for children up to age 18
Vision Exam Network — $10 copayment Non-Network — Reimbursed up to $45
Lenses — once every calendar year; copayment applied to all lens options Lenses — once every calendar year; copayment applied to all lens options
Single-vision lenses (per pair) Network — $25 copayment Non-Network — Reimbursed up to $30
Bifocal lenses (per pair) Network — $25 copayment Non-Network — Reimbursed up to $50
Trifocal lenses (per pair) Network — $25 copayment Non-Network — Reimbursed up to $65
Lenticular lenses (per pair) Network — $25 copayment Non-Network — Reimbursed up to $100
Polycarbonate lenses (per pair)
Applies to children up to age 18
Network — 100% coverage Non-Network — Not covered
Premium Plan Only
Standard anti-reflective coating
Network — $30 copayment Non-Network — Not covered
Premium Plan Only
Standard progressive multifocal
Network — $50 copayment Non-Network — Not covered
Frames — once every two calendar years; once every calendar year for children up to age 18 Frames1 — once every two calendar years; once every calendar year for children up to age 18
Frames1 Basic Plan
Network — Up to $125 retail allowance and 20% discount off remaining balance

Up to $55 Every Day Low Price price point at Wal-Mart or Sam’s Club locations (if included in the network). Discount off remaining balance does not apply at Walmart or Sam’s Club locations.
Non-Network — Reimbursed up to $70
Premium Plan
Network — Up to $175 retail allowance and 20% discount off remaining balance

Up to $77 Every Day Low Price price point at Walmart or Sam’s Club locations (if included in the network). Discount off remaining balance does not apply at Walmart or Sam’s Club locations.
Non-Network — Reimbursed up to $70

Contact Lenses — once every calendar year in place of eye glass lenses Contact Lenses — once every calendar year in place of eye glass lenses
Elective 1
If member prefers contacts to glasses

Retail allowances may be used over multiple visits in the same calendar year.
Basic Plan
Network — Up to $125 retail allowance and 15% discount off conventional or 10% discount off disposable remaining balance

Up to $92 Every Day Low Price price point for contact lenses at Walmart or Sam’s Club locations (if included in the network). Discount off remaining balance does not apply at Walmart or Sam’s Club locations.
Non-Network — Contact lenses reimbursed up to $105
Premium Plan
Network — Up to $175 retail allowance and 15% discount off conventional or 10% discount off disposable remaining balance

Up to $129 Every Day Low Price price point for contact lenses at Walmart or Sam’s Club locations (if included in the network). Discount off remaining balance does not apply at Walmart or Sam’s Club locations.
Non-Network — Contact lenses reimbursed up to $105
Necessary
If medically necessary with prior approval from National Vision Administrators, L.L.C. (NVA)
Network — Additional costs covered at 100% Non-Network — Contact lenses reimbursed up to $210
Fitting and Evaluation Network — $20 copayment for daily contact lenses;
$30 copayment for extended contact lenses;
$50 copayment for specialty contact lenses
Non-Network — Reimbursed up to $20 for daily contact lenses; Reimbursed up to $30 for extended or specialty contact lenses

Other Other
Optional Items (cosmetic extras) Network — Discount applied to all lens options Non-Network — Not covered
EyeEssential Discount Plan Network — When members exhaust their annual benefits, NVA offers the EyeEssential Discount Plan, which provides significant discounts on materials through participating NVA network providers. Non-Network — Not covered
LASIK Discounts Network — NVA members will pay a maximum amount for corrective laser surgery:
  • Traditional PRK – $1,500 per eye
  • Traditional LASIK – $1,800 per eye
  • Custom LASIK – $2,300 per eye
Members may receive additional benefits at LasikPlus locations nationwide:
  • Special pricing on select technologies
  • Free initial consultation and comprehensive LASIK vision exam
  • Advanced laser technologies including Wavefront and IntraLase (All-Laser LASIK)
  • Financing options available
Non-Network — Not covered
  1. Walmart and Sam’s Club Example: A member with the Premium Plan chooses a pair of frames at Walmart that cost $128. The Premium Plan pays $77, and the member pays the $51 difference.

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