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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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