Page 11 - 2013 Salus Group Benefits and Notices

Benefits Partner, LLC dba Salus Group 2013

Voluntary Vision Coverage

Voluntary vision benefits are provided by Superior Vision Services (SVS). SVS is an independent
company providing vision benefit services for groups. To find a SVS doctor call 1.800.507.3800 or visit
www.superiorvision.com .

NOTE: Members may choose between prescription glasses (lenses and frame) or contact lenses, but
not both.

1
SVS Network Provider Non-SVS Network Provider
1
Member’s Responsibilities (copays)
Eye Exam $10 copay $0
Prescription glasses (frame and/or lenses) $25 copay $0
Contact lenses Fit $25 copay Not Covered
Eye Exam
Complete eye exam by an ophthalmologist or
2
optometrist. The exam includes refraction, Covered in Full $40 Allowance
glaucoma testing and other tests necessary to
determine the overall visual health of the patient One eye exam in any period of 12 consecutive months
3
Lenses
2
Single Vision Covered In Full $40 Allowance
Covered up to the provider’s price for Covered up to the provider’s price for
Progressive Lenses
Trifocal lenses Trifocal lenses
2
Bifocals (with line) Covered in Full $60 Allowance
2
Trifocals (with line) Covered in Full $80 Allowance
2
Lenticular Covered in Full $80 Allowance
One pair of lenses in any period of 12 consecutive months
3
Frames
$130 Allowance $45 Allowance
Standard Frames
One frame in any period of 24 consecutive months
Contact Lenses
Medically necessary contact lenses (requires prior Covered in Full $210 Allowance
2
authorization approval from SVS and must meet
criteria of medically necessary) One pair on contact lenses in any period of 12 consecutive months
$120 Allowance $105 Allowance
Elective contact lenses
One frame in any period of 12 consecutive months
2
Contact Lens Fit: Standard Covered in Full Not Covered
Contact Lens Fit: Specialty $50 Allowance Not Covered

1
Where an “Allowance” is shown, You are responsible for paying any charges in excess of Allowance amount.
2
“Covered in Full” benefit is amount AFTER patient copay (if any) is paid.
3
Eyeglasses and frames are paid in lieu of Contact Lenses benefit

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