Vision - Active Employee

Vision - Active Employee
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Vision  Vision Plans  Effective September 1, 2014 

 

Out-of-Pocket Rates for 2014-2015
PLAN Employee
 
Employee
& Spouse 
Employee
& Child(ren) 
Employee
& Family 
Superior 
Vision
$7.00 $11.00 $11.24 $17.84
Superior 
Vision Plus
$11.00 $17.18 $18.40 $26.00
document RESOURCES

Superior Vision Plan Guide

Superior Vision Plus Plan Guide

Superior Vision Plans Video

Find a Vision Provider

Superior Vision Website


Mail CONTACT

Superior Vision CUSTOMER SERVICE
(800) 507-3800

CLAIMS ADDRESS
P.O. Box 967
Rancho Cordova, CA
95741-0949


Fully insured Vision Care benefits are offered by Superior Vision Services. You have two vision plan options to choose from:

  • Superior Vision (Standard Plan)
  • Superior Vision Plus (Enhanced Plan)

Both plans feature the following copayments:

  • Exam: $35
  • Materials: $0
  • Contact Lens Fitting: $35

Plan differences are highlighted in the table below.

VISION PLAN COMPARISON

Services SUPERIOR VISION
(Standard Plan)
SUPERIOR VISION PLUS
(Enhanced Plan)
In-Network Out-of-Network In-Network Out-of-Network
Exam (MD) Covered in full  1 Up to $42 Covered in full  1 Up to $42
Exam (OD) Covered in full  1 Up to $37 Covered in full  1 Up to $37
Frames $140 retail allowance Up to $53 $150 retail allowance Up to $53
Contact Lens Fitting (standard  ) Covered in full  Not covered Covered in full   Not covered
Contact Lens Fitting (standard  ) $50 retail allowance  1 Not covered $50 retail allowance  1 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 description  3 Up to $61 $120 retail allowance 5 Up to $61
Elective Contact Lenses  4 $125 retail allowance Up to $100 $150 retail allowance Up to $100

After co-pays. Co-pays apply to in-network benefits only. 
See your benefits materials for definitions of standard and specialty contact lens fittings 
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 
Contact lenses are in lieu of eyeglass lenses and frames benefit 
Overages on standard progressive lenses will be the member’s responsibility.

Services/Frequency limits for both plans:

  • Exam: 1 per plan year
  • Frames: 1 per plan year
  • Contact Lens Fitting: 1 per plan year
  • Lenses: 1 per plan year
  • Contact Lenses: 1 per plan year

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.

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