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Superior Vision Plan Details
Plan Highlights
This Plan provides primary vision care benefits including eye examinations, prescription eyewear and contact lenses offered through a broad-based provider network consisting of ophthalmologists, optometrists and opticians.
Copayment Amount*
$10 Exam
$25 Materials
$35 Contact Lens Fitting
|
Benefits |
Frequency |
In-network |
Non-Network |
| Comprehensive
Exam (by an Ophthalmologist) |
12 Months |
Covered in Full |
Up to $42.00 |
| Comprehensive
Exam (by an Optometrist) |
12 Months |
Covered in Full |
Up to $37.00 |
| Standard Lenses (per pair): | |||
| Single Vision |
12 Months |
Covered in Full |
Up to $32.00 |
| Bifocal |
12 Months |
Covered in Full |
Up to $46.00 |
| Trifocal |
12 Months |
Covered in Full |
Up to $61.00 |
| Lenticular |
12 Months |
Covered in Full |
Up to $84.00 |
| Contact Lenses (per pair)**: | |||
| Medically Necessary |
12 Months |
Covered in Full |
Up to $210.00 |
| Cosmetic (Elective)*** |
12 Months |
Up to $120.00 |
Up to $100.00 |
| Frames (Standard)*** |
24 Months |
Up to $100.00 |
Up to $48.00 |
*Copayments apply to in-network benefit and are deducted from
non-network reimbursements.
**Contact lenses are in lieu of eyeglass lenses and frames benefit.
***The insured is responsible for paying any charges in excess of this
allowance.
Definitions of Contact Lenses
Contact Lenses, Elective/Cosmetic
Elective/Cosmetic contact lenses are those that are worn solely for cosmetic
or convenience reasons. They are chosen because they are preferred over the
wearing of conventional eyeglasses. Contact lenses covered by the Plan must
contain a prescription for correcting a vision deficiency. Charges over the
benefit allowance are paid directly to the provider.
Contact Lenses, Medically Necessary
These lenses must be specifically prescribed by the eye doctor to be used
for the reason or reasons described below. Reimbursement for these lenses will
be considered as payment-in-full when utilizing an in-network provider.
Aphakia (after
cataract surgery without implant lens). A pair of prescription single vision or
multifocal eye glass lenses and an eyeframe can be provided along with contact
lenses prescribed for this reason.
When visual acuity
cannot be corrected to 20/70 in the better eye except through the use of contact
lenses (must be 20/60 or better).
Anisometriopia of
4.0 diopters or more, provided visual acuity improves to 20/60 or better in the
weak eye.
Kerataconus
Note: The narrowing of visual fields due to high minus or high plus corrections is not considered a reason for medically necessary contact lenses.
Contact Lens Examining
Fee:
Most providers charge a fee for the fitting of contact
lenses. This fee is separate from the eye examination and will vary depending on
the providers fee structure policies. It will also vary due to circumstances or
complexities involving the physiological condition of the eyes, the lens
prescription, and the type of lenses used. The contact lens exam/fitting fee may
be included in the contact lens allowance.
Limitations & Exclusions
Limitations (options at additional cost):
Example: Standard design bifocal lenses are a covered benefit. Blended (no line) bifocal lenses will require an additional charge.
A frame that costs more than the Plan allowance.
Additional costs for contact lenses (elective) over the allowance.
Blended (no-line) and/or multifocal lenses
Beveled and/or faceted lenses.
Coating on lenses (anti-scratch, anti-reflective, sunglass colors)
Cosmetic lenses
Oversize charge for lenses larger than Plan allowance
Polycarbonate lenses.
Replacement frames and/or lenses
Exclusions (products & services not covered):
There is no benefit coverage for the following products and services.
Conditions covered by workers compensation
Eye exams required by the employer as a condition for employment
Frame cases
Low (subnormal) vision aids
Non-prescription (plano) eyewear
Orthoptics or vision training and any associated supplemental testing
Progressive lenses
Services and materials provided by another vision plan
Tints (except Rose tint #1 and #2)
Discount Programs
| Eyeframes | 30% off |
| Lenses (uncoated std glass or plastic) | 30% off |
| Add-on features | 20% off |
| Everyday "Frames & Lenses" package pricing | 20% off |
| Contact Lenses | 20% off |
| Disposable Contacts | 10% off |
| Other Items | 20% off |
Refractive Surgery Discounts & Cosmetic Eyelid Surgery Discounts are available: Superior Vision Services has a nationwide network of refractive surgeons 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 blephoraplasty (cosmetic eyelid surgery) to Superior Vision Plan members on the same discount basis.
Note: The discount benefit is available only from Superior Vision Plan in-network providers who are identified in the provider directory with a "DP."
Discount SVP8-20
These discounts apply to upgrades
on the covered frame and lenses only. For discounts on additional pairs, please
refer to the Discounts on Additional Purchases.
|
Frames
|
20% off the difference between the covered frame allowance and the retail price of the selected frame. |
|
Add-ons to the covered pair of lenses |
|
|
Factory Scratch Coat |
$13 (Single Vision & Standard
Lined Multifocal Lenses) |
|
Member pays |
|
|
Power over 4.00
Sphere, 2.00D Cylinder & 5.00D Prism |
20% discount off retail |
|
* Higher end or brand name lens upgrades
are at an additional expense to the member. You may apply the
maximum out of pocket expense toward the upgraded lens retail cost
and the member is responsible for the difference less 20%. Progressive Power Lens Benefit (no-line): The member pays the difference between the providers price for Standard Trifocal lenses and the price of the progressive power lenses selected, less 20%. |
|
How to use your benefit
Procedure when using a Superior Vision Plan in-network provider:
2. After eligibility is established, and an authorization number is received by the provider, services will be rendered. There is nothing else that you need to do except pay the provider directly for any appropriate copayments and charges above the covered benefits. The in-network provider handles all claims and paperwork.
Procedure when using a Superior Vision Plan non-network provider:
1. To receive services from a non-network provider, it is important that
you first call Superior Vision Services Member Service Department at
800-507-3800 to receive your own authorization number. By doing so, you can
be assured of your eligibility and reimbursement for money spent.
2. After receiving services and paying in-full for the examination and/or materials (you do not pay a copayment to the non-network provider), submit your original itemized billing received from the provider, along with your authorization number, to the SVS Claims Administration office listed on the next page.
3. You will be reimbursed according to the schedule of allowances for non-network providers, less any required copayments.
Note: This is only a summary of the benefit plan. You may review and/or obtain a copy of the Master Policy and Certificate of Coverage by contacting your Human Resources/Employee Benefits Office.
This plan is underwritten by National Guardian Life Insurance Company. National Guardian Life Insurance Company is not affiliated with The Guardian Life Insurance Company of America, a/k/a The Guardian or Guardian Life.
Superior Vision Plan
Monthly Rates
|
Employee Only |
$9.78 |
|
Employee + One Dependent |
$18.98 |
|
Employee + Family |
$27.88 |
