Participating providers shall charge Members no more than the fee schedule rates listed below for listed vision care services. Participating providers may require Members to pay for vision care services in accordance with the participating provider agreement at the time service is rendered. Participating providers are not obligated to charge Members any specified rates for vision services performed after Member's Protective Vision membership is terminated.
The following are the Vision Care service fees that members shall be entitled to when visiting a participating provider. (Please discuss all fees with your participating provider prior to beginning treatment).
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EXAMINATIONS
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Examination
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$50
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Contact Lens Examination
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20% off Retail
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Comprehensive Examination
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18% off Retail
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FRAMES
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Retail Price $0-$69.99
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15% off Retail
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Retail Price $70-$139.99
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20% off Retail
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Retail Price $140+
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25% off Retail
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LENSES
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Single Vision
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$44
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Bifocal round seg ft. 25, 28
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$62
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Bifocal round. ft. 35 exec. blended
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$67
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Progressive Bifocals (Unspecified Brand)
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$135
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Sola VIP, Adapter
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$148
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VIP Gold Varilux, Percepta by Sola
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$160
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Trifocal 7/28
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$87
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Trifocal 8/35
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$93
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Cataract - Lenticular
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$93
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Cataract - Other
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$115
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SPECTACLE LENS ADD ONS
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Ultra Violet 400
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$17
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Anti-Reflective
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$48
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Fashion Tint
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$14
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Gradient Tint
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$16
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Photochromic
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$27
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Scratch Coat
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$16
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Roll & Polish Edges
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$19
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Standard Faceting
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$54
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Polycarbonate Single Vision
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$37
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Polycarbonate ft. 25, 28, 7/28 Trifocal
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$39
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Transition Plus Single Vision
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$71
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Transition Plus Ft. 28
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$77
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Transition Plus 7/28 Trifocal/Progressive
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$88
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High Index Plastic Standard - 1.56
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$42
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High Index Plastic Deluxe - 1.60
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$65
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Sphere Power over 4 D or over 2.00 D Cylinder/Pair/Diapter
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$8/pair/diapter
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Glass Lenses Single Vision
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$8
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Glass Lenses Bifocal Lenses
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$10
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Glass Lenses Tint (add per pair for glass lenses only)
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$16
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All other lens add ons not listed
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20% off Retail
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CONTACT LENSES
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Fitting Fees, Return Visits, as per providers usual practice
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20% off Retail
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Regular Contact Lenses
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20% off Retail
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Disposable Contact Lenses
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10% off Retail
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SUNGLASSES
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Non-Prescription Sunglasses
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25% off Retail
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For Prescription Sunglasses, please see discounts for frames and lenses. Sunglass tint will be charged at providers' usual and customary rate.
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Other Charges:
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Broken Appointments (Optometrist only) $25
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All discounts will be off regular, non-sale retail price. If sale price is lower than program discount price, sale price must be honored.
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CHARGES TO MEMBERS
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WHEN MEMBERS HAVE VISION INSURANCE
In accordance with Section 2.02 of the participating provider agreement, participating provider shall provide vision care services at the rates required in the agreement to persons insured by self-insured groups or insurance companies.
In California, eye exams, contact lens exams, fitting fee, and all other professional services are excluded from the program and shall be charged at the provider's usual and customary rates.
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