Shown below is a custom flat material allowance plan for a private label Student Resources client called Student Arabian Cultural Mission (SACM). This plan has no exam benefit and no materials copay, it is just a materials allowance plan.
This plan has a total dollar material allowance ($200) that can be used for eyewear frames/lenses or contact lenses. Members cannot use this allowance in multiple visits throughout the benefit. Retail cost of material should be applied to the allowance. Once the total allowance is reached members are responsible for any additional costs.
The contact lens fitting cost should be deducted from the material allowance and is NOT considered part of the exam. The contact lens benefit does not use formulary. The members’ allowance will be used towards the providers’ retail price per box for all contact lenses with the member paying any balance over their allowance. All lenses will be supplied by the provider.
|Revised Retail Plan Codes: 2.12.2016|
|Retail Plan Code||Client||Effective Date||Situs State||St. Eligible||Plan Set-up Standard/Custom|
|3W||Student Arabian||1/2016||N/A||N/A||Custom Material Allowance plan that|
|Cultural Mission||can be used towards any eyewear|
|(SACM) Student||lens/frame or contact lens purchase|
|Resources||in a single visit|