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Eligible Dependents:
• spouses;
• children (including your natural born children of you or your spouse or civil union partner,
adopted children (from date of placement for adoption), or step-children) under age 26;
and
• disabled dependent children age 26 and older.
Employee Contributions: You are required to contribute towards the cost of the coverage you
elect at the rates established each year by your Employer.
Insurance Effective Date: January 1, 2021
New Hire Effective Date: Coverage will become effective on the first of the month coinciding
with, or next following, the date on which the employee becomes a Full-Time Employee.
Date Coverage Terminates: Last day of the month in which termination (or loss of eligibility)
occurs.
Benefits:
This program generally pays an amount equal to the lesser of the provider’s charge or the
maximum allowable expense described in the benefits booklet. Benefits are subject to the payment
of a deductible each benefit period depending on the service (exams - $10; contact lens fitting and
evaluation - $60; frames and lenses $25). You may visit any vision provider of your choosing, but
note that participating providers agree to provide services at a discounted fee.
Please refer to the benefits booklet for more information.
Continuation Coverage Rights Under COBRA
COBRA is available for the Vision Benefits only. Please see the section of this booklet entitled
CONTINUATION OF COVERAGE UNDER COBRA.
COBRA Contact:
Benefit Coordinators Corporation
Two Robinson Plaza
Suite 200
Pittsburgh, Pennsylvania 15205
1-800-978-7948
enterpriseservice@benxcel.com
12
DB1/ 117253798.15
