Page 12 - TVS 2021 Benefits Guide

VOLUNTARY VISION

Vision insurance is through Guardian. Please see below for a high level
To view your weekly description of the plan. More detailed beneit summaries are available

vision contribution through Human Resources.
rates, please visit
the enrollment Guardian OAP Out-of-Network
website . Copay
Exam $10 copay $50 max beneit after
$10 copay
Materials $25 copay Varies after $25 copay
Lenses
Single $25 copay $48 max beneit after
$25 copay
Bifocal $25 copay $67 max beneit after
$25 copay
Trifocal $25 copay $86 max beneit after
$25 copay
Frames Plan will pay $135 retail after $48 max beneit after
$25 copay $25 copay
Contacts—Elective
Formulary $25 copay $105 max beneit after
Non-Formulary $135 max (copay waived) $25 copay
Medically Necessary $25 copay $210 max beneit after
$25 copay
Frequency
Exam 12 months
Lenses 12 months
Contacts 12 months
(in lieu of glasses)
Frames 24 months

Vision Provider Search
1. Go to www.guardiananytime.com

2. Click on “Find a Provider” on the top right

3. Click on “Find a Vision Provider”
4. Select the “Davis Vision” Network

5. Enter search criteria
6. Click on “Continue” to view results

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