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What Is Covered

 

Co-payment
None

NVA Participating Provider

Non-Participating Provider

Examination

Once Every Plan Year

Covered 100%

Reimbursed Amount up to $35

Lenses

Once Every Plan Year
  • Single Vision
  • Bifocal
  • Trifocal
  • Lenticular
  • Progressives
  • Fashion Gradient Tint
  • Standard Scratch Coating
  • Solid Tints
  • UV Coatings
  • Polycarbonates

 

 

Standard Glass or Plastic
Covered 100%



  • Up to $30
  • Up to $40
  • Up to $60
  • Up to $80
  • Up to $61*
  • N/A
  • N/A
  • N/A
  • N/A
  • N/A

 

Frames

Once Every Two Plan Years

 

Retail Allowance - Up to $125 (20% discount off balance)**

Up to $45

Contact Lenses

Once Every Plan Year

Elective Contact Lenses

Medically Necessary****

 

In lieu of Lenses

  • Up to $125 Retail1 (15% discount (Conventional) or 10% discount (Disposable) off balance)***
  • Covered 100%

 

In lieu of Lenses

  • Up to $125
  • Up to $250

*Includes standard lens allowance
**Does not apply to Wal-Mart / Sam's Club locations
***Does not apply to Wal-Mart / Sam's Club or Contact Fill and the following locations: Target, Sears, JC Penney, Boscov's, Pearle, K-Mart, & Macys
****Pre-approval from NVA required

1Additional professional services related to contact lenses (also known as fitting fees) would be included in the contact lens allowance shown above.

Lens options purchased from a participating NVA provider will be provided to the member at the amounts listed in the fixed option pricing list below:

  • $65  Transitions Single Vision Standard
  • $70  Transitions Multi-Focal Standard
  • $40  Standard Anti-Reflective
  • $20  Glass Photogrey (Single Vision)
  • $30  Blended Bifocal (Segment)
  • $30  Glass Photogrey (Multi-Focal)
  • $55  High Index
  • $56  Polarized (Single Vision)*
  • $66  Polarized (Multi-Focal)*

*Polarized will be $75 at the following locations: Target, Sears, JC Penney, Boscov's, Pearle, K-Mart, & Macys

Options not listed will be priced by NVA providers at their reasonable & customary retail price less 20%.

Wal-Mart / Sam's Club Stores: Due to their everyday low prices Wal-Mart / Sam's Club will not provide the lens options at the fees listed in the fixed option pricing list. Wal-Mart / Sam's Club stores accept NVA for materials. Doctors affiliated with Wal-Mart / Sam's Club are not Wal-Mart / Sam's Club employees; therefore, participation for exams varies.

 

  
Vision Care
What Is Covered
What Is Not Covered
When Your Coverage Ends
   
Related Forms
Claim Form for Non-Participating Providers
Schedule of Vision Benefits
EyeEssential Plan
   

Related Links
National Vision Administrators

    Important Legal Information:
Appoquinimink Benefits Online provides only an overview of your benefits from Appoquinimink School District and The State of Delaware. Appoquinimink School District and The State of Delaware reserve the right to amend or to terminate any benefit plan at any time, with or without notice. Review more important legal information about your benefits plans.

Copyright ©2006 Valley Forge Benefits Consulting, Inc.