Page 13 - Leona Arizona Employment Group Flipbook

Vision Plan

The vision plan provides coverage for routine eye exams and pays for all or a portion of the cost of glasses or contact lenses.
You can choose any provider; however, you always save money if you see in-network providers. We offer a vision plan through
Superior Vision. For more information, visit www.superiorvision.com.

Superior Vision
Plan Provision In-Network Out-of-Network
1
Exam
 Ophthalmologist Covered at 100% Up to $34 retail
 Optometrist Covered at 100% Up to $26 retail
Frames $130 retail allowance Up to $63 retail

Standard Lenses (Per Pair)
 Single Vision Lenses Covered at 100% Up to $29 retail
 Bifocal Lenses Covered at 100% Up to $43 retail
 Trifocal Lenses Covered at 100% Up to $53 retail
1
 Progressives Lens Upgrade See description Up to $53 retail
 Polycarbonate (For Dependent Children) Covered at 100% Not covered
Contact Lenses $130 retail allowance Up to $100 retail
2
Contact Lens Fitting 3
 Standard Covered at 100% Not covered
 Specialty $50 retail allowance Not covered

Frequency (Based on Date of Service)
 Exam 12 months 12 months
 Frames 12 months 12 months
 Standard Lenses 12 months 12 months
 Contact Lenses 12 months 12 months
 Contact Lens Fitting 12 months 12 months
Note: Copays apply to in-network benefits; copays for out-of-network visits are deducted from reimbursements.
¹ Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal,
plus applicable copay.
² Contact lenses are in lieu of eyeglass lenses and frames benefit.
³ Standard contact lens fitting applies to a current contact lens user who wears disposable, daily wear, or extended wear lenses only. Specialty contact lens fitting
applies to new contact wearers and/or a member who wears toric, gas permeable, or multi-focal lenses.

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