2022 - 9 - Summary of Benefits H1036265001 
Covered Medical and Hospital Benefits (cont.)  
•Medicare-covered diabetic eye exam:  $0 copay 
•Medicare-covered glaucoma screening:  $0 copay 
•Medicare-covered eyewear (post-cataract):  $0 copay  
Routine vision:  
In-Network: 
VIS178 
•$0 copayment for routine exam up to 1per year. 
•$115 maximum benefit coverage amount per year for contact  
lenses, eyeglasses-lenses and frames, fitting for eyeglasses-lenses