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Johns Hopkins Student Health Program Plan — 2021-2022

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Johns Hopkins Routine Vision Care Network ProvidersOut Of Network Providers
Contact Lenses
Medically necessaryUp to $600Up to $225
ElectiveUp to $150, plus 15% discount on charges above $150Up to $75
Materials
Single vision100% of allowed amountUp to $25
Bifocal100% of allowed amount ($0 copay - ultraviolet protective coating, standard progressive lenses, plastic photosensitive lenses) ($20 copay -blended segment lenses, photochromatic glass lenses) ($30 copay- intermediate vision lenses, polycarbonate lenses) ($35 copay - standard anti reflective coating) ($48 copay - premium anti reflective coating)($55 copay - hi-index lenses) ($60 copay - ultra anti reflective coating) ($70 copay select progressive lenses)($75 copay- polarized lenses) ($90 copay- premium progressive lenses) ($195 copay- ultra progressive lenses)Up to $35
Trifocal100% of allowed amount ($0 copay - ultraviolet protective coating, standard progressive lenses, plastic photosensitive lenses) ($20 copay - blended segment lenses, photochromatic glass lenses) ($30 copay- intermediate vision lenses, polycarbonate lenses) ($35 copay - standard anti reflective coating) ($48 copay - premium anti reflective coating)($55 copay - hi-index lenses) ($60 copay - ultra anti reflective coating) ($70 copay select progressive lenses)($75 copay- polarized lenses) ($90 copay- premium progressive lenses) ($195 copay- ultra progressive lenses)Up to $45
Lenticular100% of allowed amount ($0 copay - ultraviolet protective coating, standard progressive lenses, plastic photosensitive lenses) ($20 copay - blended segment lenses, photochromatic glass lenses) ($30 copay- intermediate vision lenses, polycarbonate lenses) ($35 copay - standard anti reflective coating) ($48 copay - premium anti reflective coating)($55 copay - hi-index lenses) ($60 copay - ultra anti reflective coating) ($70 copay select progressive lenses)($75 copay- polarized lenses) ($90 copay- premium progressive lenses) ($195 copay- ultra progressive lenses)Up to $45
FramesUp to $150, plus 20% discount on charges above $150Up to $30
Vision Exam
Vision Exam100% of allowed amount (one routine exam or contact lens fitting fee every 12 months; contact lens fitting fee may be provided in lieu of eye exam, but not in the same benefit year)up to $30 (one routine exam or contact lens fitting fee every 12 months; contact lens fitting fee may be provided in lieu of eye exam, but not in the same benefit year)
Revised
September 9, 2022
Group Number
E00016
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