Each material benefit is paid out once per calendar year. Exam $10 copay Up to $42 Glasses Lenses (Single / Bifocal/ Trifocal / Lenticular) $15 copay Up to $40 Up to $60 Up to $85 Glasses Frames $15 copay, then $130 allowance, 20% off remaining balance Up to $45 Contact Lenses (Medically Necessary & Elective) $15 copay, then $130 allowance, 20% off remaining balance Up to $210/$105 IN NETWORK OUT-OF-NETWORK