Page 13 - Leona Arizona Employment Group Flipbook
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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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