*Contact lenses are in lieu of eyeglass lenses and frames benefit.
**The insured is responsible for paying any changes in excess of this allowance.

How to use your benefit:

In-Network
• Select a provider from the Superior Vision Services Provider Network.
• Use your personalized I.D. card to identify yourself. Provider will call SVS to verify eligibility. No paperwork is required from you.
• Pay the provider directly the co-pay for exam and the cost of any non-covered item.

Out-of-Network
• Call SVS Member Services for your authorization number.
• Pay the non-network provider for all products and services.
• Submit your original itemized billing from the provider, along with your authorization number to SVS Member Services for reimbursement in accordance with the Non-Network Schedule of Allowances less the co-pay if applicable.

Discount Programs
Discounts available from participating providers on additional pairs of eyeglasses and contact lenses.

20% Discount off the UCR surgical fee for refractive surgery procedures such as, Radial Keratotomy (RK), Photo-Refractive Keratomy (PRK), and LASIK at a preferred provider.

Note: The discount benefit is available only from Superior Vision Plan in-network providers who are identified in the provider directory with a "DP." Discounts do not apply to the insured benefit underwritten by National Guardian Life Insurance Company.

Exclusions (products & services not covered):
There is no benefit coverage for the following products and services.

• Professional Services and/or Materials in conjunction with:

• blended bifocals, no line, or progressive lenses

• compensated or special multi-focal lenses

• plain (non-prescription) lenses

• anti-reflective, scratch, UV400, or any coating or laminate applied to lenses • subnormal vision aids

• tints, other than solid

• orthoptics, vision training and developmental vision procedures

• polycarbonate lenses

• Medical or surgical treatment of the eyes

• Any eye examination or any corrective eyewear required by an Employer as a condition of employment

• Any injury or illness when covered under Workers’ Compensation or similar law

• Plain or prescription sunglasses, no-line bifocals, blended lenses are not covered; an Insured may elect to apply the maximum allowance for standard lenses toward his, or her cost of progressive lenses

• Subnormal vision aids

• Services rendered or Materials purchased outside the U.S. or Canada unless

• the member resides in the U.S. or Canada; and

• Charges in excess of the Usual, Customary and Reasonable charges for the Professional Service or Materials

• Experimental or non-conventional treatment or device

• Safety eyewear

• Spectacle lens styles, materials, treatments, or "add-ons" not shown in the Benefits Summary

• Services or Materials rendered by a provider other than an Ophthalmologist, Optometrist or Optician acting within the scope of his, or her license

• Any additional service required outside basic vision analysis for contact lenses, except fitting fees

• Services rendered after the date an Insured ceases to be covered under this Certificate, except when vision Materials ordered before coverage ended are delivered, and the services rendered to the Insured within 31 days from the date of such order

• Services rendered or Materials ordered before the date of coverage began under this Certificate

• Regardless of Optical Necessity, benefits are not available more frequently than that which is specified in the Benefits Summary

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