Page 18 - 2019 Busey
P. 18
VISION
Bi-Weekly Rates Eye doctors detect problems in vision, overall eye health, and signs of
Associate only $2 .87 other health conditions like diabetic eye disease, high blood pressure and
Associate + spouse $5 .43 high cholesterol. We know your eyesight is precious to you, so we provide
Associate + child(ren) $5 .56 vision beneits to make sure your trip to the eye doctor is reasonably
Family $7 .52 priced.
Guardian offers associates comprehensive vision coverage. Keep in mind,
the information in the chart provided is a summary only. Please refer to
your Certiicate of Coverage (COC) for complete details of plan beneits,
limitations, and exclusions OTL. Visit www.guardiananytime.com.
In-Network Out-of-Network
Vision Exam
Exam copay $10 copay Up to $50 reimbursement
Lenses
Single lens $25 copay Up to $48 reimbursement
Bifocal lens $25 copay Up to $67 reimbursement
Trifocal lens $25 copay Up to $86 reimbursement
Frames
Frame beneit $130 allowance then 20% Up to $48 reimbursement
discount on amount over
allowance
Contacts Lenses
Elective $130 allowance then 15% Up to $105 reimbursement
discount on amount over
allowance
Visually required $0 copay; paid-in-full Up to $210 reimbursement
Frequency
Exam 12 months 12 months
Lenses 12 months 12 months
Contacts (in lieu of 12 months 12 months
glasses)
Frames 24 months 24 months
For provider search information, see page 7.
18 2019 Benefits Enrollment
Bi-Weekly Rates Eye doctors detect problems in vision, overall eye health, and signs of
Associate only $2 .87 other health conditions like diabetic eye disease, high blood pressure and
Associate + spouse $5 .43 high cholesterol. We know your eyesight is precious to you, so we provide
Associate + child(ren) $5 .56 vision beneits to make sure your trip to the eye doctor is reasonably
Family $7 .52 priced.
Guardian offers associates comprehensive vision coverage. Keep in mind,
the information in the chart provided is a summary only. Please refer to
your Certiicate of Coverage (COC) for complete details of plan beneits,
limitations, and exclusions OTL. Visit www.guardiananytime.com.
In-Network Out-of-Network
Vision Exam
Exam copay $10 copay Up to $50 reimbursement
Lenses
Single lens $25 copay Up to $48 reimbursement
Bifocal lens $25 copay Up to $67 reimbursement
Trifocal lens $25 copay Up to $86 reimbursement
Frames
Frame beneit $130 allowance then 20% Up to $48 reimbursement
discount on amount over
allowance
Contacts Lenses
Elective $130 allowance then 15% Up to $105 reimbursement
discount on amount over
allowance
Visually required $0 copay; paid-in-full Up to $210 reimbursement
Frequency
Exam 12 months 12 months
Lenses 12 months 12 months
Contacts (in lieu of 12 months 12 months
glasses)
Frames 24 months 24 months
For provider search information, see page 7.
18 2019 Benefits Enrollment
