Copayment Amount - $0 - Exam Only
Contact Lense Fitting Fee - $0
Vision Plan - Preferred Provider (PPO/Indemnity)

* Contact lense are in lieu of eyeglass lenses 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 lense user who wears diposable, daily wear, or extened wear lenses only. The specialty contact lens fitting fee applies to new contact lens and/or a member who wears toric, gas permeable, or multifocal lenses. For the specialty fit, the member is repsonsible for any charges over $50.

How to use your benefit
In-Network

• Select a provider from the Superior Vision Services Provider Network.
• Use your personalized ID card to identify yourself. Provider will call SVS to very eligibility. No paper work is required from you.
• Pay the provider directly for 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 you original itemized billing fromt he provider, along with your authorization number, to SVS Member Services for reimbursement in accordance with Non-Network Schedule of Allowances.

Discount Programs
Discounts available from participating providers on additional pairs of eyeglasses contacts lenses.

Discounty SVP8-20

*Higher end or brand name lens upgrades are at an additional expense to the member. Apply maximum out of pocket expense toward the upgraded lens retial cost and the member is responsible for the difference less 20%.

Discounts of Additional Purchases

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 procedures of blephoraplasty (cosmetic eyelid surgery) to Superior Vision Plan members on the same discount.

Exclusion (products & services not covered)
1. Professional Services and/or Materials in conjunction will
a. blended bifocals, no line, or progressive lenses
b. compensated or special multi-focal lenses
c. plain (non-prescription) lenses
d. anti-reflective, scratch, UV400 or any coating or lamination applied to lenses
e. subnormal vision aids
f. tints other than solid
g. orthoptics, vision training and development vision procedures
h. polycarbonate lenses
2. Medical or surgical treatment of the eyes
3. Any eye examination or any corrective eyewear required by an Employer as a condition of employement
4. Any injury or illness when covered under Workers' Compensation or similar law
5. 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 progressive lenses
6. Subnormal vision aids
7. Services rendered or Materials purchased outside the U.S. or Canada, unless
a. the Member reisdes in the U.S. or Canada; and
b. the charges are incurred while on a business or pleasure trip
8. Charges in excess of the Usual, Customary, and Reasonable charge for the Professional Service or Materials
9. Experimental or non-conventional treatment device
10. Safety eyewear
11. Spectacle lens styles, materials, treatments, or "add-ons" not shown in the Benefits Summary
12. Services or Materials rendered by a provider other than an Ophthalmologist, Optometrist or Optician acting within the scope of his or her license
13. Any additional service required outside basic vision analysis for contact lenses, except fitting fees
14. 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
15. Services rendered or Materials ordered before the date of coverage began under this Certificate
16. Regardless of Optical Necessity, benefits are not available more frequently that which is specified in the Benefit Summary

NOTE: This is only a summary of the benefits plan. You may review and/or obtain a copy of the Master Policy and Certificate of Coverage by contacting your Human Resources Office.

Visa/MasterCard/Bank Draft Only
*Payment cannot be payroll deducted*

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