City of Nacogdoches 2021 Enrollment Guide
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VISION INSURANCE - HIGH PLAN<br />
CARRIER: LINCOLN FINANCIAL<br />
NETWORK: SPECTERA<br />
● You will pay less out <strong>of</strong> pocket when you choose an in-network provider.<br />
● Locate an in-network provider at www.myspectera.com.<br />
● You must submit a claim form for out-<strong>of</strong>-network expenses.<br />
● LASIK surgery discounts available<br />
ELECTION<br />
MONTHLY EMPLOYEE COST<br />
Employee Only $9.33<br />
Employee & Spouse $17.68<br />
Employee & Child(ren) $20.75<br />
Employee & Family $29.19<br />
COVERED BENEFITS IN-NETWORK OUT-OF-NETWORK<br />
Eye Exam (every 12 months) $10 copay Up to $40 reimbursement<br />
Lenses (every 12 months)<br />
Single: 100% after $10 copay<br />
Bifocal: 100% after $10 copay<br />
Trifocal: 100% after $10 copay<br />
Lenticular: 100% after $10 copay<br />
Single: $40 copay reimbursement<br />
Bifocal: $60 copay reimbursement<br />
Trifocal: $80 copay reimbursement<br />
Lenticular: $80 copay reimbursement<br />
Frames (every 12 months) Up to $130 allowance Up to $45 reimbursement<br />
Contact Lenses (every 12 months)<br />
Elective<br />
Covered<br />
Medically Necessary<br />
Up to $125 allowance<br />
100% after $10 copay<br />
100% after $10 copay<br />
Up to $125 reimbursement<br />
Up to $125 reimbursement<br />
Up to $210 reimbursement<br />
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