Blue Cross Blue Shield FEP Vision
Section 5 Vision Services and Supplies
Section 5 Vision Services and Supplies
Eyewear
Benefit Description
Lenses: one pair every calendar year
Lenses include choice of glass or plastic lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, ultraviolet protective coating, oversized and glass-grey #3 prescription sunglass lenses.
Note: All lenses include scratch resistant coating with no additional copayment. There may be an additional charge at Costco, LensCrafters, Target Optical, Pearle Vision, Sam’s Club, Walmart and Warby Parker.
Note: You may choose prescription glasses or contacts.
High Option – You Pay
In-Network: Nothing
Out-of-Network: Expenses in excess of fee schedule allowance of:
$25 single vision
$35 bifocal
$45 trifocal
$45 lenticular
Standard Option – You Pay
In-Network: $10 copay
Out-of-Network: All charges
Lenses: one pair every calendar year
Lenses include choice of glass or plastic lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, ultraviolet protective coating, oversized and glass-grey #3 prescription sunglass lenses.
Note: All lenses include scratch resistant coating with no additional copayment. There may be an additional charge at Costco, LensCrafters, Target Optical, Pearle Vision, Sam’s Club, Walmart and Warby Parker.
Note: You may choose prescription glasses or contacts.
High Option – You Pay
In-Network: Nothing
Out-of-Network: Expenses in excess of fee schedule allowance of:
$25 single vision
$35 bifocal
$45 trifocal
$45 lenticular
Standard Option – You Pay
In-Network: $10 copay
Out-of-Network: All charges
Benefit Description
Optional Lenses and Treatments
High Option – You Pay – In-Network Only
Anti-Reflective (AR) Coatings - Standard/Premium/Ultra/Ultimate: $20/$33/$45/$70
Blended Segment Lenses: $20
Blue Light Filtering Lenses: $15
Digital single vision & computer lenses: $30
Edge Polish: $22
Hi-Index Lenses (1.67/1.74): $55/$120
High Luster Edge Polish: $70
Intermediate Vision Lenses: $30
Mirror Coating: $86
Photochromic Glass Lenses: $20
Plastic Photosensitive Lenses (Transitions®): No-Copay
Polarized Lenses: $75
Polycarbonate Lenses: No-Copay
Premium Scratch Resistant: $30
Progressives Lenses - Standard/Premium/Ultra/Ultimate: $0/$40/$90/$125
Rimless Drill: $66
Roll & Polish: $16
Roll Edge: $24
Scratch Protection Plan: $0
Scratch Resistant Coating: $0
Scratch Resistant Premium: $30
Slab Off: $186
Specialty Lens (myodisc/double sided grind) and Lenticular): $206
Tinted Lenses: No-Copay
Trivex Lenses: $50
Ultraviolet Protective Coating: No-Copay
Standard Option – You Pay – In-Network Only
Anti-Reflective (AR) Coatings - Standard/Premium/Ultra/Ultimate: $35/$48/$60/$85
Blended Segment Lenses: $20
Blue Light Filtering Lenses: $15
Digital single vision & computer lenses: $30
Edge Polish: $22
Hi-Index Lenses (1.67/1.74): $55/$120
High Luster Edge Polish: $70
Intermediate Vision Lenses: $30
Mirror Coating: $86
Photochromic Glass Lenses: $20
Plastic Photosensitive Lenses (Transitions®): $65
Polarized Lenses: $75
Polycarbonate Lenses: No-Copay
Premium Scratch Resistant: $30
Progressives Lenses - Standard/Premium/Ultra/Ultimate: $50/$90/$140/$175
Rimless Drill: $66
Roll & Polish: $16
Roll Edge: $24
Scratch Protection Plan: $0
Scratch Resistant Coating: $0
Scratch Resistant Premium: $30
Slab Off: $186
Specialty Lens (myodisc/double sided grind) and Lenticular): $206
Tinted Lenses: No-Copay
Trivex Lenses: $50
Ultraviolet Protective Coating: No-Copay
Optional Lenses and Treatments
High Option – You Pay – In-Network Only
Anti-Reflective (AR) Coatings - Standard/Premium/Ultra/Ultimate: $20/$33/$45/$70
Blended Segment Lenses: $20
Blue Light Filtering Lenses: $15
Digital single vision & computer lenses: $30
Edge Polish: $22
Hi-Index Lenses (1.67/1.74): $55/$120
High Luster Edge Polish: $70
Intermediate Vision Lenses: $30
Mirror Coating: $86
Photochromic Glass Lenses: $20
Plastic Photosensitive Lenses (Transitions®): No-Copay
Polarized Lenses: $75
Polycarbonate Lenses: No-Copay
Premium Scratch Resistant: $30
Progressives Lenses - Standard/Premium/Ultra/Ultimate: $0/$40/$90/$125
Rimless Drill: $66
Roll & Polish: $16
Roll Edge: $24
Scratch Protection Plan: $0
Scratch Resistant Coating: $0
Scratch Resistant Premium: $30
Slab Off: $186
Specialty Lens (myodisc/double sided grind) and Lenticular): $206
Tinted Lenses: No-Copay
Trivex Lenses: $50
Ultraviolet Protective Coating: No-Copay
Standard Option – You Pay – In-Network Only
Anti-Reflective (AR) Coatings - Standard/Premium/Ultra/Ultimate: $35/$48/$60/$85
Blended Segment Lenses: $20
Blue Light Filtering Lenses: $15
Digital single vision & computer lenses: $30
Edge Polish: $22
Hi-Index Lenses (1.67/1.74): $55/$120
High Luster Edge Polish: $70
Intermediate Vision Lenses: $30
Mirror Coating: $86
Photochromic Glass Lenses: $20
Plastic Photosensitive Lenses (Transitions®): $65
Polarized Lenses: $75
Polycarbonate Lenses: No-Copay
Premium Scratch Resistant: $30
Progressives Lenses - Standard/Premium/Ultra/Ultimate: $50/$90/$140/$175
Rimless Drill: $66
Roll & Polish: $16
Roll Edge: $24
Scratch Protection Plan: $0
Scratch Resistant Coating: $0
Scratch Resistant Premium: $30
Slab Off: $186
Specialty Lens (myodisc/double sided grind) and Lenticular): $206
Tinted Lenses: No-Copay
Trivex Lenses: $50
Ultraviolet Protective Coating: No-Copay
Benefit Description
Frame: Covered once every calendar year.
Receive an additional $50 towards your frame allowance at MyEyeDr. locations.
*Note: Additional discounts are available from participating providers except Costco, LensCrafters, Target Optical, Pearle Vision, Sam’s Club, Walmart and Warby Parker.
Note: “Collection” frames with retail values up to $195 are available at no cost at most participating independent providers. Retail chain providers typically do not display the “Collection,” but are required to maintain a comparable selection of frames that are covered in full.
High Option – You Pay
In-Network: Collection Frame: Nothing
Nothing for frames up to $200 frame allowance. Additionally, a 20% discount applies to any amount over $200*
$250 frame allowance at MyEyeDr. locations. The additional 20% discount does not apply.
Out-of-Network: Expenses in excess of fee schedule allowance of $30
Standard Option – You Pay
In-Network: Collection Frame: Nothing
Nothing for frames up to $140 frame allowance. Additionally, a 20% discount applies to any amount over $140*
$190 frame allowance at MyEyeDr. locations. Additional 20% discount does not apply.
Out-of-Network: All charges
Frame: Covered once every calendar year.
Receive an additional $50 towards your frame allowance at MyEyeDr. locations.
*Note: Additional discounts are available from participating providers except Costco, LensCrafters, Target Optical, Pearle Vision, Sam’s Club, Walmart and Warby Parker.
Note: “Collection” frames with retail values up to $195 are available at no cost at most participating independent providers. Retail chain providers typically do not display the “Collection,” but are required to maintain a comparable selection of frames that are covered in full.
High Option – You Pay
In-Network: Collection Frame: Nothing
Nothing for frames up to $200 frame allowance. Additionally, a 20% discount applies to any amount over $200*
$250 frame allowance at MyEyeDr. locations. The additional 20% discount does not apply.
Out-of-Network: Expenses in excess of fee schedule allowance of $30
Standard Option – You Pay
In-Network: Collection Frame: Nothing
Nothing for frames up to $140 frame allowance. Additionally, a 20% discount applies to any amount over $140*
$190 frame allowance at MyEyeDr. locations. Additional 20% discount does not apply.
Out-of-Network: All charges