Fully insured Vision Care benefits are offered by Superior Vision Services. Valuable information can be found on the Superior Vision website at www.superiorvision.com/ut.
| Covered Services1 |
Network Benefits |
Out-of-Network Benefits |
| Comprehensive eye exam by an ophthalmologist or optometrist |
Covered in full after $35 Copay (does not include the contact lens exam or fitting fees) See below for information about benefit for Contact Lens Fitting Fees. |
Up to $42 (ophthalmologist)
Up to $37 (optometrist) |
| Standard lenses (per pair) - plastic (CR39), clear, uncoated |
Covered in full |
Up to $32 (single vision)
Up to $46 (bifocal)
Up to $61 (trifocal)
Up to $84 (lenticular) |
| Frames |
Covered in full up to $140 retail allowance |
Up to $53 |
| Contact lenses2 |
Up to $125 retail allowance (elective/cosmetic)
Covered in full (non-elective/medically necessary). See additional explanation below. |
Up to $100 (elective/cosmetic)
Up to $210 (non-elective/
medically necessary) |
| Standard Contact Lens Fitting3 |
Covered in full after a $35 Copay
(separate from comprehensive eye exam copay)
|
No out-of-network benefit |
| Specialty Contact Lens Fitting3 |
Covered in full after a $35 Copay
up to an
allowance of $50
(separate from comprehensive
eye exam copay)
|
No out-of-network benefit |
1Only one comprehensive exam is covered per plan year. Only one pair of eyeglass lenses and one set of frames or one contact lens allowance is covered per plan year.
2Contact lenses in lieu of eyeglass lenses and one set of frames
3Standard contact lens fitting fee applies to a current contact lens user who wears disposable, 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 after the copayment is paid.
All costs and allowances are retail; you are responsible for any charges in excess of the retail allowances. All final determinations of benefits, administrative duties, and definitions are governed by the certificate of insurance for your specific benefits.
Additional discounts are available on LASIK, lens options and upgrades and mail-order contacts.
