2026 CODAC Benefit Summaries and Carrier Flyers

VISION CARE BENEFITS

The Plan will pay for Covered Expenses for vision care Incurred by a Covered Person, subject to any required Deductible, Co-pay if applicable, Plan Participation amount, maximums, and limits shown on the Schedule of Benefits. Benefits are based on the Reasonable and Allowed Amount.

COVERED BENEFITS

Eye exam. Refraction.

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EXCLUSIONS

Benefits will NOT be provided for any of the following:

Sunglasses or subnormal vision aids.

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• The fitting and/or dispensing of non-prescription glasses or vision devices, whether or not prescribed by a Physician or optometrist. • Correction of visual acuity or refractive errors. • Aniseikonia. • Lenses. ➢ Single. ➢ Bifocal. ➢ Trifocal. ➢ Lenticular. ➢ Progressive. • Frames. • Contacts. • Contact lens fitting. • Vision therapy services (including orthoptics) or supplies. • Safety lenses and frames. • Eye surgeries used to improve or correct eyesight for refractive disorders, including LASIK surgery, radial keratotomy, refractive keratoplasty, or similar surgery.

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