| Service/Material |
Participating |
Non-Participating* |
Vision Examination:
|
$5.00 Copayment |
Up to: $30.00 Retail Value |
| Frame: |
Up to: $100.00 Retail Value |
Up to: $65.00 Retail Value |
| Lenses: (Clear, Standard, Glass or Plastic) |
|
|
| Single Vision (per pair) |
Paid in full |
Up to: $25.00 Retail Value |
| Bifocal (per pair) |
Paid in full |
Up to: $35.00 Retail Value |
| Trifocal (per pair)** |
Paid in full |
Up to: $45.00 Retail Value |
| Lenticular (per pair) |
Paid in full |
Up to: $80.00 Retail Value |
| Contact Lenses:*** |
|
|
| Elective |
Up to:$135.00 |
Up to: $100.00 Retail Value |
| Medically Required |
Paid in full |
Up to: $150.00 Retail Value |
| Non-covered Eyewear Discount |
20% (Does not apply at Walmart Vision Center |
|
| Frequency: |
|
|
| Vision Examination |
Once Each 12 Months |
| Frame |
Once Each 12 Months |
| Lenses |
Once Each 12 Months |
| Contact Lenses |
Once Each 12 Months |