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