Jay School Corporation BENEFIT In-Network Out-of-Network Provider (Reimbursement up to) Plus In-Network In-Network Provider Provider Lens Options Anti-Reflective Coating – Standard $45 Copayment $45 Copayment $23 Anti-Reflective Coating – Premium $57 Copayment $57 Copayment $23 Tier 1 Anti-Reflective Coating – Premium $68 Copayment $68 Copayment $23 Tier 2 Anti-Reflective Coating – Premium $85 Copayment $85 Copayment $23 Tier 3 Photochromic Non-Glass Lens $0 Copayment $0 Copayment $38 Dependent Children under 19 years of age Polycarbonate Lenses – Standard $0 Copayment $0 Copayment $20 Dependent Children under 19 years of age Scratch Coating – Standard $0 Copayment $0 Copayment $8 Plastic S-9184 1B Exam/Materials