Page 14 - UPDATED - 8-1-24 Heritage School Benefit Guide
P. 14

Vision Option:



          Humana





                      2024 Rate Information

           Per Monthly Pay Period                                          Dependent Information


           Employee Only                          $ 12.05     We offer our employees the opportunity to cover their
                                                              spouses and dependent children. Children can join or
           Employee + Spouse                      $ 24.10     remain on a parent’s vision plan until age 26. When a
                                                              child turns 26, they will lose vision coverage on the last
           Employee + Child(ren)                  $ 22.90     day of their birth month.
           Employee + Family                      $ 35.99


                       Frequency limitations are based on date of last service and not on calendar year.



                      Benefits—Vision 160 Plan                                 In-Network Coverage


         Copays:
           Exam                                                                         $10 Copay

           Materials                                                                    $10 Copay
           Standard Contact Fitting                                                     No Charge
         Frequency:
           Exams                                                                     Every 12 Months

           Lens                                                                      Every 12 Months
           Frames                                                                    Every 12 months

         Standard Lens:
           Single Vision                                                        Covered in Full after Copay
           Lined Bifocal                                                        Covered in Full after Copay
           Lined Trifocal                                                       Covered in Full after Copay

           Standard Progressive                                               Add on to Bifocal Copay + $10
           Scratch Resistant, UV Coating and Tints                            Covered in Full after $15 Copay

           Frames:
           Frames Allowance                                               $160 Retail allowance + 20% off overage
         Contact Lenses in lieu of eye glasses, materials only:

           Frequency                                                                 Every 12 Months
           Lens Allowance                                                 $160 Retail allowance + 15% off overage

                                  Please note:  This is intended for general information purposes.
            It is not a guarantee of benefits.  Please reference the Benefit Summary or contact the carrier for specific details.

         14
   9   10   11   12   13   14   15   16   17   18   19