and frames. 
•Eyeglass lens options may be 
available with the maximum 
benefit coverage amount up to 
1pair per year. 
•Maximum benefit coverage 
amount is limited to one time 
use per year. 
•Benefits received 
out-of-network are subject to 
any in-network benefit 
maximums, limitations, and/or 
exclusions. 
MENTAL HEALTH SERVICES 
Inpatient 
Your plan covers up to 190 days 
in alifetime for inpatient mental 
health care in apsychiatric 
hospital $750 copay per admit 30% of the cost