| Covered Services | In-Network and Out-of-Network |
| Class I Benefits | |
| Focuses on eyes and overall wellness | 100% |
| Class II Benefits | |
| Frames $150 allowance; 20 percent savings on amount over allowance | $25 |
| Lenses Single, lined bifocal and trifocal, polycarbonate for dependent children | $25 |
| Contacts (instead of glasses) $150 allowance; copay does not apply, contact lens exam (evaluation and fitting) | $25 |