VISION PLAN BLUE CROSS BLUE SHIELD OF MA 20/20 VISION PLAN In-Network Out-of-NetworkReimbursement EyeExam – Benefit available every 12 months $10copay Up to $50 Frames – Benefit available every 24 months Allowance $150 allowance, then additional 20% off the balance Up to $90 Lenses &Enhancements – Benefit available every 12 months SingleVision $25 copay Up to $42 LinedBifocal $25 copay Up to $78 Lined Trifocal Lenses $25 copay Up to $130 StandardProgressive $90 copay Up to $130 ContactLenses – Benefit available every 12 months Conventional $150 allowance, then additional 15% off the balance Up to $120 Disposable $150 allowance Up to $120 Medically Necessary Paid in full Up to $210 Vision Summary of Benefits 2024 Benefits Guide | 14