Mark III Employee Benefits - City of LaFayette, GA

Out-of-network
• 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 $10 exam and $15 materials copays.

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 the covered pair of lenses
• Factory Scratch Coat • Ultraviolet Coat • Standard Anti-Reflective coat* • High Index 1.6* • Polycarbonate • Plastic Tints solid or gradient • Glass coloring • Standard transitions and other standard photochromic lenses* • Power over 4.00D Sphere, 2.00D Cylinder & 5.00D Prism • Cosmetic Finishing, Beveling, Edging & Mounting 20% discount off retail prices • Miscellaneous Options 20% discount off retail prices	20% discount up to $13 maximum out of pocket 20% discount up to $15 maximum out of pocket 20% discount up to $50 maximum out of pocket 20% discount up to $55 maximum out of pocket 20% discount up to $40 maximum out of pocket 20% discount up to $25 maximum out of pocket 20% discount up to $35 maximum out of pocket 20% discount up to $80 maximum out of pocket 20% discount off retail prices 20% discount off retail prices 20% discount off retail prices
*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 retail cost and the member is responsible for the difference less 20%.

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:

• blended bifocals, no line, or progressive lenses
• compensated or special multi-focal lenses
• plain (non-prescription) lenses
• anti-reflective, scratch, UV400, or any coating or laminate applied to lenses • subnormal vision aids
• tints, other than solid
• orthoptics, vision training and developmental vision procedures
• polycarbonate lenses

• 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. Once the Master Policy and Certificate of Coverage is issued, you may review and/or obtain a copy by contacting Human Resources.

Benefits	Frequency	In-network	Non-Network
Comprehensive Exam (Ophthalmologist)	12 Months	Covered in Full	Up to $44.00
Comprehensive Exam (Optometrist)	12 Months	Covered in Full	Up to $39.00
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
*Contact Lenses (per pair):**	12 Months
Medically Necessary	12 Months	Covered in Full	Up to $210.00
Cosmetic (Elective**)	12 Months	Up to $100.00	Up to $100.00
Frames (Standard)**	24 Months	Up to $100.00	Up to $50.00

• Prescription eyeglass lenses	30% discount off retail prices
• Eyeframes	30% discount off retail prices
• Add-on charges to basic lenses	20% discount off retail prices
• Contact lenses, standard hard or soft	20% discount off retail prices
• Disposable contact lenses	10% discount off retail prices
• All other prescription materials	20% discount off retail prices

Employee Only	$10.80
Employee + 1 Dependent	$20.96
Employee + Family	$30.80