LSU Student Vision Plan

Service

In-Network

Out-of-Network

Exam: $15 co-pay Up to $35
Materials: $15 co-pay

Standard Plastic Lenses:

Single Vision Covered Up to $25
Bifocal Covered Up to $40
Trifocal Covered Up to $50
Lenticular $80 allowance Up to $50
Progressive $70 allowance Up to $40

Frames:

Member may select any frame available Up to $120 retail allowance Up to $50 retail allowance

Contact Lenses (*):

Fit, follow-up & materials: No co-pay
- Elective Up to $120 Up to $100
- Medically Necessary Up to $210 Up to $210
Vision Frequencies
Exam 1 per 12 months
Standard Plastic Lenses 1 per 12 months
Frames 1 per 24 months
Contact Lenses (*) 1 per 12 months
Vision Rates (valid August 2011 through July 2012)
Annual Fall Spring / Summer Three Payment Nine Payment Summer
Student $125 $72 $72 $51 $23 $35
Student +1 $237 $128 $128 $88 $36 $59
Student + Family $400 $209 $209 $143 $54 $93

This is a primary vision care benefit and is intended to cover only eye examinations and corrective eyewear. Medical or surgical treatment of eye disease or injury is not provided under this plan. Covered Materials that are lost or broken will be replaced only at normal service intervals indicated in the Plan Design; however, these materials and any items not covered above may be purchased at Preferred Pricing from a Participating Provider.

(*) In lieu of eyeglass lenses and frames.

Disclaimer: This information is for illustrative purposes only. This document does not amend or alter the coverage provided by the actual insurance policies and contracts. Please see the Master Policy for specific policy information and exclusions.