Greeneville City Schools, TN | Plan Year: January 1, 2006 - December 31, 2006

Vision Plan       Vision Plan Details   Rates         Superior Vision Contact                                 All other questions, please call your Personnel Office.

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Superior Vision Plan Details

Outline of Benefits - Gold Preferred Plan With Materials Discount
Vision Plan - Preferred Provider (PPO / Indemnity)
Copayment Amount
$10.00 Exam, $ 15.00 Materials

· 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.

· 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.

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 ReliaStar LIfe Insurance Company.

Limitations (options at additional cost):
The Superior Vision Plan is designed to provide your basic eyewear needs. It does not cover items that are considered cosmetic or elective. The following options will require an additional charge over the covered benefit. Pay any additional charges directly to your provider.

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)