LSU Student Vision Plan
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Service
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In-Network
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Out-of-Network
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Exam:
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$10 co-pay
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Up to $35
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Materials:
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$10 co-pay
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Standard Plastic Lenses:
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Single Vision
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Covered
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Up to $25
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Bifocal
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Covered
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Up to $40
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Trifocal
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Covered
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Up to $50
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Lenticular
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$80 allowance
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Up to $50
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Progressive
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$70 allowance
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Up to $40
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Frames:
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Member may select any frame available
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Up to $120 retail allowance
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Up to $50 retail allowance
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Contact Lenses (*):
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Fit, follow-up & materials:
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No co-pay
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- Elective
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Up to $120
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Up to $100
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- Medically Necessary
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Up to $210
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Up to $210
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Vision Frequencies
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Exam
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1 per 12 months
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Standard Plastic Lenses
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1 per 12 months
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Frames
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1 per 24 months
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Contact Lenses (*)
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1 per 12 months
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Vision Rates
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Annual
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Fall
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Spring / Summer
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Three Payment
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Nine Payment
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Summer
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08/14/08 - 08/13/09
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08/14/08 - 01/05/09
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01/06/09 - 08/13/09
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08/14/08 - 08/13/09
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08/14/08 - 08/13/09
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06/05/09 - 08/13/09
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Student
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$94.32
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$47.16
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$47.16
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$31.44
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$10.48
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$23.58
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Student +1
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$179.28
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$89.64
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$89.64
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$59.76
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$19.92
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$44.82
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Student + Family
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$302.40
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$151.20
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$151.20
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$100.80
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$33.60
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$75.60
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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.
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