Vision

Fully insured Vision Care benefits will continue to be offered by Superior Vision Services. Superior Vision continues to build and enhance their network and administration. 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)	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	Up to $53
Contact lenses	Covered in full (non-elective/ medically necessary)2 Up to $125 retail (elective/cosmetic)3	Up to $210 (non-elective/ medically necessary) 2 Up to $100 (elective/cosmetic)3
NEW! Standard Contact Lens Fitting3	Covered in full after a $35 Copay (separate from comprehensive eye exam copay)	No out-of-network benefit
NEW! 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 an existing 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.

Contact Lenses

Contact lenses (non-elective/medically necessary) are covered in full for members who have one or more of these medical conditions*:

• Aphakia
• Anisometropia
• Kerataconus
• When visual acuity cannot be corrected to 20/70 in the better eye except through the use of contact lenses

*Prior authorization is required.
Contact lenses (elective) are also covered for those who prefer to wear contacts instead of glasses. Mail order contact lenses are available at www.SVContacts.com.

LASIK Procedure

Superior Vision offers discounted rates off the usual and customary prices for LASIK surgery. These discounts vary depending on the provider but are the best possible discounts available to Superior Vision.

Additional Discount Features

Item Covered	Discount
Frames (Discounts do not apply when prohibited by manufacturer.)	20% off the difference between the covered frame allowance and the retail prices of the selected frame
Lens Options/Upgdade - Standard Single Vision Lenses - Scratch Coat (factory)* - UV Coat - Standard AR Coat* - High Index 1.6* - Photochromics - Polycarbonate	20% off retail; your out-of-pocket will not exceed: $13 $15 $50 $55 $80 $40
Lens Options/Upgdade - Standard Lines Bi and Tri-focal Lenses - Scratch Coat (factory)* - UV Coat - Standard AR Coat* - High Index 1.6** - Photochromics** - Polycarbonate**	20% off retail; your out-of-pocket will not exceed: $13 $15 $50 20% off retail (with no out-of-pocket limit) 20% off retail (with no out-of-pocket limit) 20% off retail (with no out-of-pocket limit)
Additional Services available on any lens - Plastic Tints Solid or Gradient - Glass Coloring - Power over 4.00 D Sphere, 2.00 Cylinder or 5.00 D Prism - Cosmetic Finishing, Beveling, Edging or Mounting - Miscellaneous Options	20% off retail; your out-of-pocket will not exceed: $15 $50 20% off retail (with no out-of-pocket limit) 20% off retail (with no out-of-pocket limit) 20% off retail (with no out-of-pocket limit)

* Higher-end or brand-name lens upgrades are at an additional expense to member.
** An out-of-pocket limit does not apply to these lens upgrades or add ons.
*** Discounts available from specific providers only.

NOTE: These discounts are available from specific providers contracted to honor the Discount Plan.  Two providers that do not participate in the Discount Plan are Wal-Mart Vision Centers and Sam’s Clubs.  Please check the Superior Vision website for additional confirmation of Discount Plan providers.

Superior Vision’s SmartAlert Program!

Superior Vision’s SmartAlert provides an easy way to foster communication between you, your Superior Vision eye care provider and your primary care physician or specialist.  Vision exams can play an important role in the accurate diagnosis and monitoring of conditions, which may impact your total wellness or larger health issues.  The SmartAlert program provides you and your Superior Vision eye doctor an important conduit for sharing the findings of your eye exam, at your discretion, with your primary care physician or wellness plan administrator.

SmartAlert includes a valuable member tool to assist you in preparing and sharing information about your lifestyle and environment with your Superior Vision provider.  This tool is the My Vision Lifestyle Update* form and is located on the Superior Vision website at www.superiorvision.com/ut in the Member portal.  You should print a copy of the form, review and answer the questions carefully, then share this form with your Superior Vision provider during your next eye exam appointment.

*Superior Vision Services makes no representation about the suitability of this information for medical purposes or any other purpose. In no event shall Superior Vision be liable for any special, indirect, or consequential damages whatsoever, arising out of or in connection with the use of this form.