National Vision Administrators
Coverage period: January 1, 2024 – December 31, 2024
| Services | In-Network | Out-of-Network |
| Examination Once Every Plan Year |
Covered 100% | (Reimbursement Amounts) Up to $35 |
| Lenses Once Every Plan Year |
Standard Glass or Plastic Covered 100% | Single Vision Up to $25 Bi-focal Up to $45 Tri-focal Up to $75 Lenticular Up to $75 |
| Frame Once Every Plan Year |
Covered up to $85 Retail Allowance 3 (20% discount off remaining balance over $85 allowance) 4 |
Up to $45 |
| Contact Lenses Once Every Plan Year |
(In lieu of Lenses/Frames) | (In lieu of Lenses/Frames) |
| Elective | Covered up to $60 Retail Allowance 5 (15% discount (Conventional) or 10% discount (Disposable) off remaining balance over $60) 6 | Up to $45 |
| Fit & Follow-Up 1 | ||
| Standard Daily Wear | Covered 100% | Daily Wear: $20 |
| Standard Extended Wear | Covered 100% | Extended Wear: $30 |
| Specialty Wear | Covered 100% after $10 Copay | Specialty: $50 |
| Medically Necessary 2 | Covered 100% | $120 |
- Covered only if member chooses Contact Lenses.
- Prior Authorization required from NVA. Includes fitting & follow-up.
- Includes frames up to $32 Every Day Low Price-price point at Walmart/Sam’s Club locations (if included in network).
- Discount does not apply at Walmart/Sam’s Club locations or for certain proprietary frame brands or where prohibited by law.
- $42 Every Day Low Price-price point for contact lenses at Walmart/Sam’s Club locations (if included in the network).
- Discount does not apply at Walmart/Sam’s Club locations, Cole corporate locations (if applicable) or Contact Fill. Prohibited by some manufacturers or where prohibited by law.
NOTE: If covered participants choose extra options, they are responsible for the additional cost of the options paid directly to the ECP
