SCHEDULE OF VISION BENEFITS

PLANS III (3), V (5) & VI (6):

Maximum Vision Care Benefit per Fiscal year:
Eye Refaction$60.00
Frames & Single Vision Lenses$150.00
Frames & Bi-Focal Lenses$160.00
Frames & Tri-Focal Lenses$170.00
Frames & Progressive Lenses$170.00
Lenticular Lenses (per pair)$170.00
Contact Lenses (in lieu of glasses)$150.00

 

PLAN II (2):

Maximum Vision Care Benefit per Fiscal year:Plan II
Co-Pays
Eye Refraction$50.00$10.00
Frames & Single Vision Lenses$90.00$60.00
Frames & Bi-Focal Lenses$100.00$60.00
Frames & Tri-Focal Lenses$110.00$60.00
Frames & Progressive Lenses$110.00$60.00
Lenticular Lenses (per pair)$110.00$60.00
Contact Lenses (in lieu of glasses)$90.00$60.00

 

Poly-Carb Lenses are ok. If packaged and under allowable amount, A/R Coating & Scratch Resistant Coating are ok.

 

ITEMS NOT COVERED:

  • Transition Lenses.

 

BILLING ADDRESS:

IPM HEALTH & WELFARE TRUST OF CALIFORNIA
1168 E. LA CADENA DRIVE
RIVERSIDE, CA 92507
(951) 684-1791
HOURS: 8:00 AM TO 4:30 PM (M-F)