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Superior Vision Plan Details
Plan Highlights
Co-payment for exam:
$15.00 Materials
Co-payment for materials:
$35.00 Contact Lens Fitting
|
Benefits |
Frequency |
In-network |
Non-Network |
| Lenses (Standard) 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 $57.00 |
| Lenticular | 12 months | Covered in Full | Up to $90.00 |
| 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 $210.00 |
| Frames (Standard)** | 24 months | Up to $100.00 | Up to $100.00 |
*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.
Discount Programs
Discounts are available from participating providers on additional pairs of
eyeglasses and contact lenses.
| Eyeframes | 30% off retail prices |
| Lenses (uncoated std glass or plastic) | 30% off retail prices |
| Add-on features | 20% off retail prices |
| Everyday "Frames & Lenses" package pricing | 20% off retail prices |
| Contact Lenses | 20% off retail prices |
| Disposable Contacts | 10% off retail prices |
| Other Items | 20% off retail prices |
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.
Note: Discounts do not apply when prohibited by the manufacturer.
Add-on charges to covered pair of lenses
|
Lens Options and Upgrades |
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) |
| All Other Lens Options/Upgrades | 20% off retail prices (any type lenses) |
* 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 Vison Plan in-network provider:
1. Identify yourself to the in-network provider as a member of the Superior Vision Plan. You can use your ID card for this purpose or simply give the provider your name, employer name, and your social security number. The provider will call SVS Member Services to verify your eligibility and obtain an authorization number. The ID card provided to you can be used for all covered family members.
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 Vison 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.
Superior Vision Plan
Tenthly (10 Pay) Rates
| Monthly Cost | |
| Employee Only | $7.80 |
|
Employee and One Dependent |
$15.10 |
| Employee & Family |
$22.20 |