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SCHEDULE OF VISION EXPENSE BENEFITS

CITY OF LEWISVILLE

Plan Benefits Effective: October 1, 2010



Vision Care Benefits
Benefits
Reimbursement Amount
Eye Exam (Once each plan year)
$50
Pair of Lenses (Each plan year)
        § Single vision
        § Bifocal
        § Trifocal
        § Lenticular
$35
$50
$60
$100
rames (Each plan year)
$75
Contact Lenses (In Lieu of Eyeglasses/Each plan year)
$100

Both Contact Lenses and Eyeglasses (Frames and Lenses) not allowed in same Plan Year.
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