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Superior Vision Plan Details
Outline of Benefits - Gold
Preferred Plan With Materials Discount
CoPayment Amount - $20.00 Exam Only
Vision Plan - Preferred Provider (PPO / Indemnity)
|
Benefits |
Frequency |
In-network |
Non-Network |
| Comprehensive
Exam (Ophthalmologist) |
12 Months |
Covered in Full |
Up to $44.00 |
| Comprehensive
Exam (Optometrist) |
12 Months |
Covered in Full |
Up to $39.00 |
| Standard Lenses (per pair): | 12 Months | ||
| Single Vision | 12 Months | Covered in Full | Up to $34.00 |
| Bifocal | 12 Months | Covered in Full | Up to $48.00 |
| Trifocal | 12 Months | Covered in Full | Up to $64.00 |
| Lenticular | 12 Months | Covered in Full | Up to $88.00 |
| Contact Lenses (per pair)*: | 12 Months | ||
| Medically Necessary | 12 Months | Covered in Full | Up to $210.00 |
| Cosmetic (Elective**) | 12 Months | Up to $100.00 | Up to $100.00 |
| Frames (Standard)** | 24 Months | Up to $100.00 | Up to $50.00 |
*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 paper work is required from you.
Pay the provider directly for the $20 exam co-pay 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 $20 exam co-pay if
applicable.
Discount Programs
Discounts available from participating providers on additional pairs
of eyeglasses and contact lenses.
|
Discount SVP8-20 Frames Note: Discounts do no apply when prohibited by the manufacturer. |
20% off the difference between the covered frame allowance and the retail price of the selected frame. |
| Add-on charges to the covered pair of lenses |
Member pays 20% off retail up to: |
|
Factory Scratch Coat |
$13 (Single Vision &
Standard Multifocal lined lenses) |
| *Higher end or brand name lens upgrades are at an additional expense to the member. Apply maximum out of pocket expense toward the upgraded lens retail cost and the member is responsible for the difference less 20%. | |
Discounts of Additional Purchases
| Prescription eyeglass lenses | 30% discount off retail prices |
| Eyeframes | 30% discount off retail prices |
| Add-on charges to basic lenses | 20% discount off retail prices |
| Contact lenses, standard hard or soft | 20% discount off retail prices |
| Disposable contact lenses | 10% discount off retail prices |
| All other prescription materials | 20% discount off retail prices |
Discounts are available for additional purchases of eyewear and contact lenses. Discounts are provided by Superior Vision Services contracted providers identified in the Provider Directory with a "DP". Discounts do not apply to the insured benefit underwritten by National Guardian Life Insurance Company.
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.
Exclusions (products &
services not covered):
There is no benefit coverage for the following products and services.
|
Professional Services and/or Materials in conjunction with: |
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Medical or surgical treatment of the eyes |
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| 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 |
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, P.O. Box 1191 Madison, WI 53701-1191
Monthly RATES
| Employee Only | $9.13 |
|
Employee + Spouse |
$17.70 |
| Employee + Child |
$17.70 |
| Employee + Family |
$25.98 |
