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  • Your Benefits As of 02/09/2021: Group: Aetna Medicare Hmo

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    Emily dolcett
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    This document outlines vision benefits for Aetna Medicare HMO as of 02/09/2021. It details allowed frequencies and costs for routine and additional vision services both in-network and out-of-network. Routine exams, frames, lenses and contact lenses are covered once per calendar year for both adults and children. Additional discounts are provided for additional purchases beyond routine benefits. The plan also includes declining balance packages for materials and lists costs for lens options, contacts and LASIK services.

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    Eye Benefits

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    This document outlines vision benefits for Aetna Medicare HMO as of 02/09/2021. It details allowed frequencies and costs for routine and additional vision services both in-network and out-of-network. Routine exams, frames, lenses and contact lenses are covered once per calendar year for both adults and children. Additional discounts are provided for additional purchases beyond routine benefits. The plan also includes declining balance packages for materials and lists costs for lens options, contacts and LASIK services.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    34 views3 pages

    Your Benefits As of 02/09/2021: Group: Aetna Medicare Hmo

    Uploaded by

    Emily dolcett
    This document outlines vision benefits for Aetna Medicare HMO as of 02/09/2021. It details allowed frequencies and costs for routine and additional vision services both in-network and out-of-network. Routine exams, frames, lenses and contact lenses are covered once per calendar year for both adults and children. Additional discounts are provided for additional purchases beyond routine benefits. The plan also includes declining balance packages for materials and lists costs for lens options, contacts and LASIK services.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 3

    Your Benefits as of 02/09/2021

    Group: AETNA MEDICARE HMO


    Service Type Allowed Frequency - Adults Allowed Frequency - Kids
    Routine
    Exam Once every calendar year Once every calendar year
    Contact Lens Fit and Follow-up Unlimited Unlimited
    Frame Once every calendar year Once every calendar year
    Lenses Once every calendar year Once every calendar year
    Contact Lenses Once every calendar year Once every calendar year
    Additional Purchase
    Frame Unlimited Unlimited
    Lenses Unlimited Unlimited
    Contact Lenses Unlimited Unlimited
    **
    A calendar year is defined as January through December when a member has active coverage.

    Restrictions
    Plan allows the member to receive contacts, frame and lens services.

    Sun Declining Balance Packages


    In Network Beginning
    Materials - Frame, Lens/Lens Options and Contacts 200.00

    Routine Declining Balance Packages


    In Network Beginning
    Materials - Frame, Lens/Lens Options and Contacts 200.00

    Routine Benefits In-Network Member Cost O


    Exam Services
    Exam $0 copay N
    Retinal Imaging Up to $39 N
    Routine Benefits In-Network Member Cost O
    Contact Lens Fit and Follow-Up
    Contact Lens Fit and Follow Standard $40 N
    Contact Lens Fit and Follow Premium 10% off retail price N
    Frame
    Frame 65% of retail price applied to remaining balance N
    Lenses
    Single Vision $40 applied to remaining balance N
    Bifocal $60 applied to remaining balance N
    Trifocal $80 applied to remaining balance N
    Lenticular 80% of retail price applied to remaining balance N
    Progressive - Standard $125 applied to remaining balance N
    Progressive - Premium 80% of retail price applied to remaining balance N
    Lens Options
    Anti Reflective Coating $45 applied to remaining balance N
    Anti Reflective Coating - Premium 80% of retail price applied to remaining balance N
    Polycarbonate $40 applied to remaining balance N
    Scratch Coating $15 applied to remaining balance N
    Tint - Solid or Gradient $15 applied to remaining balance N
    UV Treatment $15 applied to remaining balance N
    All other Lens Options 80% of retail price applied to remaining balance N
    Contact Lenses
    Contacts - Conventional 85% of retail price applied to remaining balance N
    Contacts - Disposable 100% of retail price applied to remaining balance N

    Additional Purchase Benefits In-Network Member Cost O


    Frame
    Frame 35% off retail price N
    Lenses
    Single Vision $40 N
    Bifocal $60 N
    Additional Purchase Benefits In-Network Member Cost O
    Trifocal $80 N
    Lenticular 20% off retail price N
    Progressive - Standard $125 N
    Progressive - Premium 20% off retail price N
    Lens Options
    Anti Reflective Coating $45 N
    Anti Reflective Coating - Premium 20% off retail price N
    Polycarbonate $40 N
    Scratch Coating $15 N
    Tint - Solid or Gradient $15 N
    UV Treatment $15 N
    All other Lens Options 20% off retail price N
    Contact Lenses
    Contacts - Conventional 15% off retail price N
    Contacts - Disposable 100% of retail price N

    LASIK Benefits In-Network Member Cost O


    Exam Services
    Lasik or PRK From U.S. Laser Network 15% off retail or 5% off promo price; call 1-800-422-6600 N

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