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Superior Vision Plan Details
Plan 1 - Full Services
Outline of
Benefits - Gold Preferred Plan With Materials Discount
Vision Plan - Preferred Provider (PPO / Indemnity)
Copayment Amount - $20.00 Exam Only
Materials - None
|
Benefits |
Frequency |
In-Network |
Non-Network |
| Comprehensive
Exam (by an Ophthalmologist) |
12 Months |
Covered in Full |
Up to $24.00 |
| Comprehensive
Exam (by an Optometrist) |
12 Months |
Covered in Full |
Up to $19.00 |
| 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 |
| Eyeframe, or | 24 Months | Up to $100.00 | Up to $50.00 |
| Contact Lenses: | 12 Months | Up to $100.00 | Up to $100.00 |
In-network co-payment is paid directly to the
provider.
Out-of-network co-payment will be deducted from the out-of-network
reimbursement.
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 SVP8-20
Frames - 20% off the difference between the covered frame
Allowance and the retail price of the selected frame.
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):
There is no benefit coverage for the following
products and services.
| 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.
Full Services Vision Plan 1 Rates
| Monthly Cost | |
| Employee Only | $7.98 |
| Employee + Family |
$20.24 |
Superior Vision
Plan 2 - Materials Only
Outline
of Benefits - Materials Only
Vision Plan - Preferred Provider (PPO / Indemnity)
Materials Copayment - $0
|
Benefits |
Frequency |
In-Network |
Non-Network |
| Eye Exams |
No Benefit |
No Benefit |
No Benefit |
| 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 |
| Eyeframe, or | 24 Months | Up to $100.00 | Up to $50.00 |
| Contact Lenses: | 12 Months | Up to $100.00 | Up to $100.00 |
In-network co-payment is paid directly to the
provider.
Out-of-network co-payment will be deducted from the out-of-network
reimbursement.
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.
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.
Also included are discounts on the purchases or 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 (No restrictions
apply) |
30% Off Retail |
| LENS (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 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: |
|
| 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.
Materials Only Vision Plan 2
Rates
| Monthly Cost | |
| Employee Only | $5.64 |
| Employee + Family |
$13.98 |
