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Opticare15-100C Plan |
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Opticare of Utah 1901 W. Parkway Blvd., SLC, UT, 84119 Phone: (801) 886-2020, (800) EYE-CARE Fax: (801) 954-0054 |
www.opticareofutah.com | ||
USEA |
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Download enrollment form here » Return the completed enrollment form to: USEA - 864 E Arrowhead Lane - Murray, UT 84107 |
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| Select Network | Broad Network | Out-of-Network | |
Eye exam |
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| Eyeglass exam | $15 Co-pay | $25 Co-pay | $35 Allowance |
| Contact exam | $15 Co-pay | $25 Co-pay | $35 Allowance |
| Dilation | 100% Covered | Retail | Included above |
| Contact Fitting | 100% Covered | Retail | Included above |
Lenses *Standard Plastic |
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| Single Vision | 100% Covered | $10 Co-pay | $85 Allowance |
| Bifocal (FT 28) | 100% Covered | $10 Co-pay | for lenses, options |
| Trifocal (FT 7x28) | 100% Covered | $10 Co-pay | and coatings |
Lens Options |
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| Progressive (Standard plastic no-line*) | $30 Co-pay | $50 Co-pay | |
| Glass lenses | 15% Discount | 15% Discount | |
| Polycarbonate | $40 Co-pay | 25% Discount | |
| High Index | $80 Co-pay | 25% Discount | |
Coatings |
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| Scratch resistant coating | 100% Covered | $10 Co-pay | |
| Ultra Violet protection | 100% Covered | $10 Co-pay | |
| Other Options - A/R, edge polish, tints, mirrors, etc. | 25% Discount | 25% Discount | |
Frames |
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| Allowance Based on Retail Pricing | $100 Allowance | $80 Allowance | $60 Allowance |
| Additional pairs of glasses throughout the year | 50% Off Retail | 25% Off Retail | |
Contacts |
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| Contact benefit is in lieu of lens and frame benefit | $100 Allowance | $80 Allowance | $60 Allowance |
| Additional contact purchases: | |||
| Conventional | Up to 20% off | Retail | |
| Disposables | Up to 10% off | Retail | |
Frequency |
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| Exams, Lenses, Frames, Contacts | Every 12 months | Every 12 months | Every 12 months |
Refractive Surgery (LASIK) |
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| $250 Off Per Eye | Not Covered | Not Covered | |
| LASIK services are not an insured benefit - this is a discount only Pre & post operative care provided by Standard Optical Based on Standard Optical Retail Fees | |||
Monthly Premiums |
Single | $8.15 | |
| Two Party | $15.88 | ||
| Family | $20.36 | ||
Discounts |
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| Any item listed as a discount in the benefit outline above is a merchandise discount only and not an insured benefit. Providers may offer additional discounts. See provider for details. | |||
Download enrollment form here » Return the completed enrollment form to: USEA - 864 E Arrowhead Lane - Murray, UT 84107
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