year for routine exam. 
•$100 combined maximum 
benefit coverage amount per 
year for contact lenses or 
eyeglasses-lenses and frames, 
fitting for eyeglasses-lenses 
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. VIS751 
•$0 copay for routine exam up 
to 1per year. 
•$75 combined maximum 
benefit coverage amount per 
year for routine exam. 
•$100 combined maximum