| Vision Plan - Preferred Provider
(PPO)/Indemnity |
|
Monthly Rates: |
|
Employee Only:
Employee & Family: |
$9.76
$20.00 |
|
Copayment: |
$20.00 Exam
$20.00 Materials |
In-Network: Copayment is paid directly to the provider.
Non-Network: Copayment will be deducted from the non-network
reimbursement.
Materials copayment applies to lenses and/or frames, not contact lenses.
|
| Full Benefit Plan Services/Frequency |
| Comprehensive Exam |
12 months |
| Lenses |
12 months |
| Frames |
24 months |
| Contact Lenses |
12 months |
|
|
| Benefits |
In-Network |
Non-Network |
| Comprehensive Exam by an Ophthalmologist (MD) |
Covered
In Full |
Up to $44.00 |
Comprehensive Exam by
an Optometrist (OD) |
Covered
In Full |
Up to $39.00 |
| Standard Lenses (Per Pair): |
|
|
| Single Vision |
Covered
In Full |
Up to $34.00 |
| Bifocal |
Covered
In Full |
Up to $48.00 |
| Trifocal |
Covered
In Full |
Up to $64.00 |
| Lenticular |
Covered
In Full |
Up to $88.00 |
| Contact Lenses (Per Pair):* |
|
|
| Medically Necessary |
Covered
In Full |
Up to $210.00 |
| Cosmetic Elective** |
Up to $100.00 |
Up to $100.00 |
| Frames Standard** |
Up to $100.00 |
Up to $100.00 |
* Contact lenses are in lieu of eyeglass
lenses and
frames benefit.
**The insured is responsible for paying any charges in
excess of this allowance. |
| |
|
|
|
Questions???
Call 800-507-3800
|
|
| Discount SVP8-20 Add on charges to the covered pair of
lenses........%20 off retail prices
|
| Additional Purchases |
Prescription eyeglass lenses............%30 off retail prices
Eyeframes......%30 off retail prices
Add-on charges to basic lenses...........%20 off retail prices
Everyday "frame & lens package pricing"..........%20 off retail prices
Contact lenses, standard hard of soft...............%20 off retail prices
Disposable contact lenses............%10 off retail prices
All other prescription materials........%20 off retail prices
Discounts are available for the add on charges to the covered pair of lenses
and additional purchases of eyewear and contact lenses. The discounts do not
apply to the insured portion of the benefit plan that is underwritten by
ReliaStar Life Insurance Company. Discounts are provided by Superior Vision
Services contracted providers identified in the provider directory with a "DP".
|
| Refractive Surgery & Cosmetic Eyelid Surgery Discount Available
with both Wellness Plus Plan and the Full Benefit Plan |
Superior Vision Services has contracted a network of over 500 refractive
surgeons nationwide who specialize in the popular elective procedures of radial
keratotomy (RK), photo-refractive keratotomy (PRK) and LASIK. These providers
offer Superior Vision Plan members a 20% discount off their usual and customary
surgical fees for these procedures. Ophthalmic plastic surgeons are also
contracted to provide the procedure of blepharoplasty (cosmetic eyelid surgery)
to Superior Vision Plan members on the same discount basis.
Discounts are provided by Superior Vision Services contracted providers
identified in the provider directory with a "RF". The refractive surgery
discount does not apply to the insured benefit underwritten by National Guardian Life Insurance Company, Madison, Wisconsin.
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