Vision Benefits

Vision insurance offers coverage for the routine care of your eyes and may provide coverage for eyeglasses and contact lenses. Your plan will pay for these services based upon the schedule
below. Be sure to check your plan certificate for details.

Keep in mind that your costs will generally be lower if you choose an in-network eye-doctor. To find an in-network eye-doctor, please visit www.mutualofomaha.com.

	In-Network	Out-of-Network
Exam	$10 Copay	Up to $37
Retinal Imaging	Up to $39	Not Applicable
Standard Contact Lens Fit & Follow-up	Up to $40	Not Applicable
Premium Contact Lens Fit & Follow-up	10% off retail price	Not Applicable
Standard Plastic Lenses
Single Vision	$25 Copay	$25 Copay
Bifocal	$25 Copay	$25 Copay
Trifocal	$25 Copay	$25 Copay
Standard Progressive (add on to Bifocal)	$65 Copay	Up to $36
Premium Progressive Lenses (add on to Bifocal)	Tier 1: $85 / Tier 2: $95 / Tier 3: $110 Tier 4: $65 + 80% of charge, less $120 allowance	Up to $36
Polycarbonate Lenses (Adults)	$40	Not Applicable
Polycarbonate Lenses (Children under age 19)	$40	Not Applicable
UV Treatment	$15	Not Applicable
Tint	$15	Not Applicable
Scratch Coating	$15	Not Applicable
Standard Anti-Reflective	$45	Not Applicable
Premium Anti-Reflective	Tier 1: $57 / Tier 2: $68 / Tier 3: 20% off retail price	Not Applicable
Photochromic-Transitions	$75	Not Applicable
Other Add-ons	20% off retail price	Not Applicable
Frames	Up to $130 allowance 20% off balance over allowance	Up to $91 allowance
Contact Lenses
Conventional	$0 copay $130 allowance 15% off balance	Up to $89
Disposable	$0 copay $130 allowance	Up to $104
Medically Necessary	$0 copay; paid in full	Up to $210
Frequency
Exam	Once every 12 months	Once every 12 months
Lenses or Contact Lenses	Once every 12 months	Once every 12 months
Frames	Once every 24 months	Once every 24 months