Page 44 - Empowered Learning for Dyslexic Children Benefits Guide 2022-2023
P. 44
The Legacy School
Vision Summary
Effective Date
February 1, 2022
CareFirst
BlueVision Plus Opt B
Benefits
$10 Exam / 12/12/24 Month
In-Network
Coinsurance 100%
Exam $10 Copay
Eye Glass Lenses Single: $20 copay
Collection: 100%
Frame Allowance Non-Collection: $130
Allowance
Collection: 100%
Contact Lenses Non-Collection: $130
Allowance
Out-of-Network
Coinsurance Allowance
Exam $45 Allowance
Eye Glass Lenses Single: $52 Allowance
Frame Allowance $60 Allowance
Contact Lenses Elective: $112 Allowance
Intervals
Exam Service 12 Mos.
Lenses & Frame Service 12 / 24 Mos.
# Rates
Individual $7.00
Parent/Child $12.95
Employee/Spouse $16.10
Family $19.60
Until the group is issued, rates can change due to rate modifications/effective date
changes, census corrections or geographic changes. This description of benefits is
intended for summary and comparison purposes only and based on our interpretation
of the plans. Please refer to the Master Contract for actual benefits.
Blue Harbor Benefits LLC
