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Materials Only Plan
Perferred Provider (PPO) Indemnity)
Copayment : $15.00 Materials
                        $25.00 Contact Lens Fittng Fee

* Contact lenses are in lieu of eyeglasses and frames benefit.
** The insured is responsible for paying any charges in excess of this allowance.
*** Standard contact lens fitting fee applies to an existing contact lens user who wears diposable, daily wear, or extended wear lenses only. The specialty contact lens fitting fee applies to new contact lens wearers and/or a member who wears toric, gas permeable, or multifocal lenses. For the specialty fit, the member is responsible for any charges over $50.

DEFINITIONS OF CONTACT LENSES
Contact/Lenses, Elective/Cosmetic
Elective/Cosmetic contact lenses are those tat 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 correctiong a vision deficiency. Changes over the benefit allowance are paid directly to the provider

CONTACT LENSE, 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.

MATERIALS SVP8-20 DISCOUNT SCHEDULE
Featured are 20% discounts on the provider's charges for upgrades to the 1st pait of covered eyeglass lenses. This includes tints, coatings special materials and special lense designs

Also included are discounts on the purchases or additional pairs of eyelglasses 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 services they provide at the location.

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 ususal and customary surgical fees for these products. Opthalmic 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 conjuction with:
  • blended bifocals, no line, or progressive
  • compensated or special multi-focal lenses
  • plain (non-perscription) lenses
  • anti-reflective, scratch, UV400, or any coating or laminate applied to lenses
  • subnormal vision aids
  • tints, other than solid
  • orthoptics, vision training and development vision procedures
  • polycarbonate lenses
• Medical or surgical treatment on the eyes
• Any corrective eyewear required by an Employer as a condition of employment
• Plain or prescription sunglasses, no line bifocals, blended lenses are not covered; an Insured my 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 Services or Materials
• Experimental or non-conventional treatment or device
• Safety eyewear
• Spectacle lens styles, materials, treatments, or "add-ons" not shown in the Benefit Summary
• Services or Materials rendered by a provider other than an Ophthalmologist, Optometrist or Optician acting within the scope of his or her license
• 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 tot he Insured within 31 days for 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 by contacting your Human Resources/Employee Benefits Office.