Vision - Active Employee

Vision Plan Monthly Premium

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)
PLAN
2022-2023		 EMPLOYEE EMPLOYEE
& SPOUSE		 EMPLOYEE
& CHILD(REN)		 EMPLOYEE
& FAMILY
Superior 
Vision 		$5.02 $7.90 $8.10 $12.84
Superior 
Vision Plus 		$7.64 $11.98 $12.82 $18.10

Both plans feature the following copayments:

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

Plan differences are highlighted in the table below. Please note additional details

    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
    after copay1     		Up to $42 Covered in full
    after copay1     		Up to $42
    Exam (OD) Covered in full
    after copay1     		Up to $37 Covered in full
    after copay1     		Up to $37
    Frames $140 retail allowance Up to $53 $165 retail allowance Up to $53
    Contact Lens Fitting (standard 2 ) Covered in full
    after copay1      		Not covered Covered in full
    after copay1      		Not covered
    Contact Lens Fitting (specialty 2 ) $50 retail allowance
    after copay1     		Not covered $50 retail allowance
    after copay1     		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 26) 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

    1  Copays for exams and contact lens fittings 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:

    • 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.

     

    Resources

    Contact

    Superior Vision CUSTOMER SERVICE (800) 507-3800

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