JHU Retirees Plan — 2022-2023
Vision Services and Supplies
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| EHP Network Provider | Out of Network Provider | |
|---|---|---|
| Contact Lenses | ||
| Medically necessary | Not Covered | Not Covered |
| Elective | Not Covered | Not Covered |
| Materials | ||
| Single vision | Not Covered | Not Covered |
| Bifocal | Not Covered | Not Covered |
| Trifocal | Not Covered | Not Covered |
| Lenticular | Not Covered | Not Covered |
| Frames | Not Covered | Not Covered |
| Vision Exam | ||
| Vision Exam | 100% of allowed amount; deductible waived (one exam every two years; excludes contact lens fitting fee) | Not Covered |
Revised
December 29, 2023
Group Number
E0005100 (*003C/*004C)
Plan Codes
225C0000
