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Superior Vision Plan 1 Full Services
Outline of Benefits -
Gold Preferred Plan With Materials Discount| Benefits | Frequency | In-network |
Non-Network |
| Comprehensive
Exam (by an Ophthalmologist) |
12 months |
Covered in Full |
Up to $44.00 |
| Comprehensive
Exam (by an Optometrist) |
12 months |
Covered in Full |
Up to $39.00 |
| Lenses (Standard) per pair: | |||
| 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): | |||
| 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 paperwork is
required from you.
Pay the provider directly for the co-pay for exam or materials 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 SVP8-20
Note: Discounts do no apply when prohibited by the manufacturer.
|
Add-on charges to covered pair of lenses: |
Member pays 20% off retail up to: |
| Factory Scratch Coat | $13 (Single Vision & Standard Multifocal lenses) |
| Ultraviolet Coat | $15 (Single Vision & Standard Multifocal lenses) |
| Standard Anti-Reflective coat* | $50 (Single Vision & Standard Multifocal lenses) |
| High Index 1.6* | $55 (Single Vision lenses only) |
| Polycarbonate | $40 (Single Vision lenses only) |
| Standard Photochromic | $80 (Single Vision lenses only) |
| Glass coloring | $35 (Any Type lenses) |
| Plastic Tints solid or gradient | $25 (Any Type lenses) |
| Power over 4.00 Sphere, 2.00D Cylinder & 5.00 Prism | 20% off retail prices (any type lenses) |
| Cosmetic finishing, Beveling, Edging, and Mounting | 20% off retail prices (any type lenses) |
| Miscellaneous Options | 20% off retail prices (any type lenses) |
* Higher end or brand name lens upgrades are at an additional expense to the member. Apply maximum out of pocket expense toward upgraded lens retail cost and member is responsible for the difference less 20%.
DISCOUNTS ON ADDITIONAL PURCHASES
|
Prescription eyeglass lenses |
30% discount off retail prices |
|
Eyeframes |
30% off discount off retail prices |
|
Add-on charges to basic lenses |
20% off discount off retail prices |
|
Contact lenses, standard hard or soft |
20% off discount off retail prices |
|
Disposable contact lenses |
10% off discount off retail prices |
| All other prescription materials | 20% off 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):
| Professional Services and/or Materials in
conjunction with: |
|
| 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 the charges are incurred while on a business or pleasure trip 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.
Plan 1 Full Services Monthly Cost
|
Employee Only |
$8.38 |
|
Employee + Spouse |
$17.82 |
|
Employee + Children |
$13.56 |
|
Employee + Family |
$24.72 |
Superior Vision Plan 2 - Materials Only
Outline of Benefits -
Gold Preferred Materials Only Plan With Materials Discount|
Benefits |
In-network |
Non-Network |
| 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 $120.00 |
Up to $100.00 |
| Frames (Standard)** |
Up to $100.00 |
Up to $50.00 |
Materials copayment only applies to lenses and frames,
not contact lenses.
Copayments apply to in network benefit and are deducted from non network
reimbursements.
SERVICES/FREQUENCY
Lenses- 12 months
Frames- 24 months
Contact Lenses- 12 months
Materials SVP
8-20 Discount Schedule
Featured are 20% discounts on the providers charges for upgrades to the
1st pair of covered eyeglass lenses. This includes tints, coatings,
special materials and special lens designs. Members may also receive a
20% discount on the difference between the retail price of the frame
they have selected, and their allowance, as shown on the benefit outline
above.
Out of Pocket Maximums for Lens Add-Ons - Single Vision Lenses
| Scratch Coat (Factory) | $13 |
| UV Coat | $15 |
| Standard Anti-Reflective Coat | $50 |
| High Index 1.6 | $55 |
| Plastic Tints Solid or Gradient | $25 |
| Standard transitions(& other standard photochromic lenses) | $80 |
| Polycarbonate | $40 |
| Glass Coloring | $35 |
Out of Pocket Maximums for Lens Add-Ons-Std Lined Bi & Tri-focal Lenses
| Scratch Coat (Factory) | $13 |
| UV Coat | $15 |
| Standard Anti-Reflective Coat | $50 |
Also included are discounts on the purchases of additional pairs of eyeglasses and contact lenses. (See the schedule below). These materials discounts are available from in-network providers who are identified in the directory with a "DP" (discount plan) associated with their listing as a service they provide at the location.
| FRAMES | 30% OFF RETAIL |
| No restrictions apply | |
| LENSES (Uncoated Plastic-CR39, or Glass) | 30% OFF RETAIL |
| Single Vision | |
| Bifocal (FT 25-35 & Executive) | |
| Trifocal (FT 7X25, 7X28, 8X35 & Executive) | |
| Progressives | |
| Zyl and Metal Mounting | |
|
ADD-ON TO BASE LENSES |
20% OFF RETAIL |
|
Tints, Coatings, Colored Lenses |
|
| Power over 4.00D Sphere, 2.00D Cylinder & 5.00D Prism | |
| Polycarbonate, High Index, Photochromatics | |
| Cosmetic Finishing, Beveling, Edging & Mounting | |
|
EVERYDAY "Frame & Lens Package Pricing" |
20% OFF RETAIL |
|
CONTACT LENSES |
20% OFF RETAIL |
|
DISPOSABLE CONTACT LENSES |
10% OFF RETAIL |
|
ALL OTHER MATERIALS |
20% OFF RETAIL |
REFRACTIVE SURGERY DISCOUNT PLAN
Plan 2 Materials Only Monthly Premium
|
Employee Only |
$6.16 |
|
Employee + Spouse |
$12.20 |
|
Employee + Children |
$11.96 |
|
Employee + Family |
$18.18 |
