North State Bank 2024 Benefits Guide

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NORTH STATE BANK | 2025 BENEFITS GUIDE

Vision:

Basic Plan Enhanced Plan In-Network Out-of-Network In-Network Out-of-Network

Copay

Exam

$10

$10

Materials

$25 $25

$10 $25

Contact Lense Fitting

Benefits

Exam (MD) Exam (OD)

Covered in Full Covered in Full

Up to $44 Up to $39

Covered in Full Covered in Full

Up to $44 Up to $39

Contact Lense Fitting(Std) Contact Lense Fitting(Spc)

Covered in Full

Not Covered Covered in Full

Not Covered

$50 Retail Allowance $130 Retail Allowance

$50 Retail Allowance $175 Retail Allowance

Not Covered

Not Covered

Frames

Up to $64

Up to $89

Lenses Single Vision - Basic Covered in Full

Up to $34 Up to $48 Up to $64

Covered in Full Covered in Full Covered in Full Covered at retail lined trifocal level

Up to $34 Up to $48 Up to $64

Bifocal - Basic Trifocal - Basic

Covered in Full Covered in Full Covered at retail lined trifocal level

Up to $64

Up to $64

Progressive - Basic

$120 Retail Allowance

$200 Retail Allowance

Contact Lenses

Up to $100

Up to $100

Basic/standard lenses do not include tinting or special coatings such as scratch, ultraviolet, reflective, etc. Monthly Employee Deduction

Employee & Spouse

Employee & Child(ren)

Employee & Family

Vision Plans

Employee

Vision Plan- Basic Plan

$0.00

$3.05

$3.25

$6.34

Vision Plan- Enhanced Plan

$1.60

$6.22

$6.34

$11.05

With both the Basic and Enhanced plans, eye exams are covered every plan year (services do not need to be 12 months apart) . Contact lenses, in lieu of frames and glass lenses, are covered every plan year as well. Frames are covered once every-other plan year.