Page 9 - SIH 2022 Re-Enrollment Guide
P. 9
2022
SIH Benefits Re-Enrollment
VISION PLAN DESIGN
Out-of-Network
Vision Care Services In-Network Member Cost
Reimbursement
Exam With Dilation as Necessary
$10 copay Up to $35
Frames
$0 copay; $120 allowance;
20% of balance over $120 Up to $50
Standard Plastic Lenses
Single Vision $25 copay Up to $25
Bifocal $25 copay Up to $40
Trifocal $25 copay Up to $55
Standard Progressive Lens $90 copay Up to $40
Premium Progressive Lens $90 copay; 20% of retail price less $120 allowance Up to $40
Contact Lens Fit and Follow-Up (Contact lens it and two follow up visits are available once a comprehensive eye exam has been completed)
Standard Contact Lens Fit and Follow-Up Up to $55 N/A
Premium Contact Lens Fit and Follow-Up 10% of retail N/A
Contact Lenses
Conventional $0 copay; $120 allowance; 15% of balance over $120 Up to $92
Disposable $0 copay; $120 allowance; plus balance over $120 Up to $92
Medically Necessary $0 copay, paid-in-full Up to $200
Frequency
Examination Once every 12 months
Lenses or Contact Lenses Once every 12 months
Frame Once every 24 months
Diabetic Care Services (Type 1 and Type 2 Diabetics)
Oice Service Visit—Up to (2) Services Per Beneit Year Covered 100%, $0 copay Up to $77
Covered 100%, $0 copay (Not covered if extended
Retinal Imaging—Up to (2) Services Per Beneit Year Up to $50
ophthalmoscopy is provided within 6 months)
Extended Ophthalmoscopy—Up to (2) Services Per Beneit Covered 100%, $0 copay (Not covered if retinal imaging is Up to $15
Year provided within 6 months)
Gonioscopy—Up to (2) Services Per Beneit Year Covered 100%, $0 copay Up to $15
Scanning Laser—Up to (2) Services Per Beneit Year Covered 100%, $0 copay Up to $33
The vision plan documents are available online by visiting Employee Self Service and Beneits Plans &
Coverage under the Home tab on the Lawson Dashboards and at beneits.sih.net. If you do not have access
to a computer, printed copies are available upon request from Human Resources.
9
SIH Benefits Re-Enrollment
VISION PLAN DESIGN
Out-of-Network
Vision Care Services In-Network Member Cost
Reimbursement
Exam With Dilation as Necessary
$10 copay Up to $35
Frames
$0 copay; $120 allowance;
20% of balance over $120 Up to $50
Standard Plastic Lenses
Single Vision $25 copay Up to $25
Bifocal $25 copay Up to $40
Trifocal $25 copay Up to $55
Standard Progressive Lens $90 copay Up to $40
Premium Progressive Lens $90 copay; 20% of retail price less $120 allowance Up to $40
Contact Lens Fit and Follow-Up (Contact lens it and two follow up visits are available once a comprehensive eye exam has been completed)
Standard Contact Lens Fit and Follow-Up Up to $55 N/A
Premium Contact Lens Fit and Follow-Up 10% of retail N/A
Contact Lenses
Conventional $0 copay; $120 allowance; 15% of balance over $120 Up to $92
Disposable $0 copay; $120 allowance; plus balance over $120 Up to $92
Medically Necessary $0 copay, paid-in-full Up to $200
Frequency
Examination Once every 12 months
Lenses or Contact Lenses Once every 12 months
Frame Once every 24 months
Diabetic Care Services (Type 1 and Type 2 Diabetics)
Oice Service Visit—Up to (2) Services Per Beneit Year Covered 100%, $0 copay Up to $77
Covered 100%, $0 copay (Not covered if extended
Retinal Imaging—Up to (2) Services Per Beneit Year Up to $50
ophthalmoscopy is provided within 6 months)
Extended Ophthalmoscopy—Up to (2) Services Per Beneit Covered 100%, $0 copay (Not covered if retinal imaging is Up to $15
Year provided within 6 months)
Gonioscopy—Up to (2) Services Per Beneit Year Covered 100%, $0 copay Up to $15
Scanning Laser—Up to (2) Services Per Beneit Year Covered 100%, $0 copay Up to $33
The vision plan documents are available online by visiting Employee Self Service and Beneits Plans &
Coverage under the Home tab on the Lawson Dashboards and at beneits.sih.net. If you do not have access
to a computer, printed copies are available upon request from Human Resources.
9
