200 Park Ave., New York, NY 10166 L0423030985[exp0426][All States] © 2024 MetLife Services and Solutions, LLC The following are optional benefit enhancements – Low Vision Once every 24 months Provides additional benefits to members who are not legally blind, but whose eyesight cannot be corrected to 20/70 with the use of optical lenses. Not available at retail chains including Costco®, Walmart® and Sam’s Club®. • Supplemental testing: Maximum of two (2) tests covered at no additional cost within a two (2) year period up to the benefit maximum. • Supplemental aids: 75% of the allowable amount up to the benefit maximum every two (2) years. • Benefit maximum: $1,000 every two (2) years. Diabetic Eyecare Plus Program Provides additional coverage for members who have been diagnosed with type 1 or type 2 diabetes and have specific ophthalmological conditions. It also provides benefits for those with glaucoma and age-related macular degeneration (AMD). In addition, members who have diabetes but don't show signs of diabetic eye disease are eligible to receive preventive retinal screenings. Not available at retail chains including Costco®, Walmart® and Sam’s Club®. • Exam: Covered in Full after $20 copay. • Special Ophthalmological services: Covered at no additional cost. Out-of-network reimbursement* You pay for services and then submit a claim for reimbursement. The same benefit frequencies for In-network benefits apply. Once you enroll, visit www.metlife.com/mybenefits for detailed out-of-network benefits information. • Eye exam: up to $45 • Single vision lenses: up to $30 • Progressive lenses: up to $50 • Frames: up to $70 • Lined bifocal lenses: up to $50 • Contact lenses: • Lined trifocal lenses: up to $65 • Elective up to $105 • Lenticular lenses: up to $100 • Necessary up to $210 *If you choose an out-of-network provider, you may have increased out-of-pocket expenses, must pay in full at time of service, and must file a claim for reimbursement. Low Vision: • Supplemental evaluation and aids: Same as in-network benefits. Diabetic Eyecare Plus Program: • Exam and other ophthalmological services - The lesser of the provider’s usual fee or up to 80% of the Medicare allowable charge.