Out-of-Pocket Rates per Month for 2014-2015
Fully insured Vision Care benefits are offered by Superior Vision Services. You have two vision plan options to choose from:
Both plans feature the following copayments:
Plan differences are highlighted in the table below.
VISION PLAN COMPARISON
|Services|| SUPERIOR VISION
| SUPERIOR VISION PLUS
|Exam (MD)||Covered in full1||Up to $42||Covered in full1||Up to $42|
|Exam (OD)||Covered in full1||Up to $37||Covered in full1||Up to $37|
|Frames||$140 retail allowance||Up to $53||$150 retail allowance||Up to $53|
|Contact Lens Fitting (standard2 )||Covered in full1||Not covered||Covered in full1||Not covered|
|Contact Lens Fitting (specialty2 )||$50 retail allowance1||Not covered||$50 retail allowance1||Not covered|
|Lenses (standard) per pair:|
|Single Vision||Covered in full||Up to $32||Covered in full||Up to $32|
|Bifocal||Covered in full||Up to $46||Covered in full||Up to $46|
|Trifocal||Covered in full||Up to $61||Covered in full||Up to $61|
|Polycarbonate for dependent children only (up to age 25)||Not Covered||Not Covered||Covered in full||Not Covered|
|Scratch Coat (factory, single sided)||Not Covered||Not Covered||Covered in full||Not Covered|
|Ultraviolet Coat||Not Covered||Not Covered||Covered in full||Not Covered|
|Progressive Lens||See description3||Up to $61||$120 retail allowance5||Up to $61|
|Elective Contact Lenses4||$125 retail allowance||Up to $100||$150 retail allowance||Up to $100|
1 After co-pays. Co-pays apply to in-network benefits only.
2 See your benefits materials for definitions of standard and specialty contact lens fittings
3 Covered at the provider's in-office retail price for a standard lined trifocal; member pays difference between the progressive and the trifocal, plus applicable co-pay
4 Contact lenses are in lieu of eyeglass lenses and frames benefit
5 Overages on standard progressive lenses will be the member’s responsibility.
Services/Frequency limits for both plans:
Additional discounts are available on LASIK, lens options and upgrades and mail-order contacts.
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.