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SUMMARY OF THE MILA NATIONAL HEALTH PLAN: VISION BENEFITS

VISION SERVICE MEMBER COST OUT-OF-NETWORK ALLOWANCE
Exam w/ Dilation $10 copay $30
Contact Lens Fit & Follow-up
Standart Contact Lens $0 copay $40
Premium Contact Lens 90% retail cost less $40 $40
Frames
Any available frame at provider location $15 copay, $100 allowance, then 20% discount $40
Standard Plastic Lenses
Single Vision $10 copay $25
Bifocal $10 copay $45
Trifocal $10 copay $80
Lenticular $10 copay $80
Standard Progressive Lens $10 copay $110
Premium Progressive Lens See Price List $110
Lens Options
UV Treatment $15 $0
Tint (solid & gradient) $0 $15
Standard Plastic Scratch Coating $0 $15
Standard Polycarbonate- Adults $0 $40
Standard Polycarbonate- Child <19 $0 $40
Standard Anti-Reflective Coating $45 $0
Polarized 20% off retail $0
Photocromatic/Transitions Plastic $75 $0
Premium Anti-Reflective Coating See Price List $0
Other Add-ons 20% off retail $0
Contact Lenses (materials only)
Conventional $10 copay, $100 allowance, then 15% discount $75
Disposable $10 copay, $100 allowance, then balance $90
Medically Necessary (See note below table) $0 copay, $500 allowance, then balance $475
Laser Vision Correction
Lasik or PRK from US Laser Network 15% off retail or 5% off promotional $0
Additional Pairs Benefit after Plan benefit has been used Members receive 40% discount off complete pair of eyeglasses and 15% discount off conventional contacts
Frequency Limits
Examination Once every 12 months
Lenses or contact lenses Once every 12 months
Frame Once every 24 months

Note: Contact lenses will be considered “medically necessary” under the Plan only when one of the following conditions exists: (1) Anisometropia of 3D in meridian powers; (2) High Ametropia exceeding -10D or +10D in meridian powers; (3) Keratoconus when the member’s vision cannot be corrected to 20/25 in either or both eyes using standard spectacle lenses; and (4) Vision improvement other than Keratoconus for Members whose vision can be corrected two lines of improvement on the visual acuity chart when compared with best corrected standard spectacle lenses. The Vision Plan benefit may not be expanded for other eye conditions even if you or your provider deems contact lenses necessary for other eye conditions or for visual improvement. However, this limitation in the Vision portion of the Plan coverage does not preclude consideration of your condition under the Medical portions of the Plan.

Price List
Member Cost for Premium Progressive Lenses
Tier I $30 copay
Tier II $40 copay
Tier III $55 copay
Tier IV $10 copay plus 80% of charge less $120
Member Cost for Premium Anti-Reflective Coating
Tier I $57 copay
Tier II $68 copay
Tier III $68 copay
Tier IV 80% of charge

One can review the list of Premium Progressive lens brands and premium Anti-Reflective Coating brands to determine the Tier of coverage at www.eyemedvisioncare.com or call Customer Service at 1-866-939-3633.