Blue Cross Blue Shield FEP Vision
Summary of Benefits

• Do not rely on this chart alone. This page summarizes specific expenses we cover; for more detail, please review the individual sections of this brochure.
   
• We offer additional benefits for children age of 13 and under as well as members with specific conditions (e.g. diabetes, hypertension) see full details in Section 5.
   
• We offer an additional $50 frame allowance if you utilize a MyEyeDr. location.
   
• If you want to enroll or change your enrollment in this plan, please visit www.BENEFEDS.com or call 1-877-888-FEDS (1-877-888-3337), TTY number 1-877-889-5680.

Covered Services In-Network
Vision Care Exams (a comprehensive exam that focuses on your eye health and overall wellness)
High Option You Pay: Nothing
Standard Option You Pay: Nothing
Page: 15 [Diagnostic]

Standard Eyeglass Lenses (Contact lenses may be obtained in lieu of glasses) Optional Lens Treatments
High Option You Pay: Nothing. Some additional copays
Standard Option You Pay: $10, Some additional copays
Page: 15 [Eyewear]

Frame Allowance - Collection Frames:
High Option You Pay: Nothing
Standard Option You Pay: Nothing
Page: 16 [Eyewear]

Frame Allowance - Frame Allowance
High Option You Pay: Any amount over the $200 Plan allowance after a 20% discount. At MyEyeDr. you pay any amount over $250 frame allowance. 20% discount does not apply.
Standard Option You Pay: Any amount over the $140 Plan allowance after a 20% discount. At MyEyeDr. you pay any amount over $190 frame allowance. 20% discount does not apply.
Page: 16 [Eyewear]

Contact Lenses
High Option You Pay: Any amount over the $150 Plan allowance after a 15% discount For Non-Specialty contact lenses the Evaluation, Fitting and Follow-up care are covered in full at network providers. Standard Option You Pay: Any amount over the $140 Plan allowance after a 15% discount
Page: 16-17 [Contact Lenses]

Laser Vision Correction
High Option You Pay: The provider’s charge after the negotiated discount
Standard Option You Pay: The provider’s charge after the negotiated discount
Page: 20 [Discounts]

See Section 4, Your Cost for Covered Services, for the Out-of-Network benefits available under High Option. See Section 5, Vision Services and Supplies for complete benefit information