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Vision Plan Monthly Premium

PLAN Retiree Retiree  
& Spouse 
Retiree  
& Child(ren) 
Retiree  
& Family 
Superior Vision $5.90 $9.30 $9.52 $15.10
Superior Vision Plus $9.00 $14.08 $15.08 $21.30

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 $165 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.


    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