Page 12 - TVS 2022 Benefits Guide

To view your weekly pay Voluntary Vision
deductions, please review Vision insurance is through Guardian. Please see

the 2022 rate sheet. below for a high level description of the plan. More
detailed beneit summaries are available through
Human Resources.

Guardian OAP Out-of-Network
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
Plan will pay $135
Frames retail after $25 copay $48 max beneit
after $25 copay
Contacts—Elective
Formulary $25 copay $105 max beneit

Non-Formulary $135 max (copay after $25 copay
waived)
Medically $25 copay $210 max beneit
Necessary after $25 copay
Frequency
Exam 12 months
Lenses 12 months
Contacts (in lieu 12 months
of glasses)
Frames 24 months

Vision Provider Search

1. Go to www.guardianlife.com

2. Click on “Find a Provider” under
“Connect with us”

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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