Page 11 - 2023-24 Gas Clip Technologies Benefit Guide EMPLOYEES

Vision Option:

Equitable

2023-24 Rate Information

Per Pay Period Semi-Monthly
Employee Only $0.69
Dependent Information

Employee + Spouse $1.38 Gas Clip Technologies offers employees the oppor-
tunity to cover their spouses and dependent children.
Employee + Child(ren) $1.48
Children can join or remain on a parent’s vision plan
Employee + Family $2.33 until age 26. When a child turns 26, they will lose vision
coverage on the last day of their birth month.
Frequency limitations are based on date of last service and not on calendar year.

Benefits — Vision In-Network Coverage

Copays:
Exam $10 Copay

Materials $25 Copay
Standard Contact Fitting Up to $60
Frequency:

Exams Every 12 Months
Lens Every 12 Months
Frames Every 24 months
Standard Plastic Lens:

Single Vision Covered in Full after $25 Copay
Lined Bifocal Covered in Full after $25 Copay

Lined Trifocal Covered in Full after $25 Copay
Lenticular Covered in Full after $25 Copay
Standard Progressive $55 Copay

Scratch Resistant $33 Copay *Discounts are subject to VSP change.
UV Coating $16 Copay *Discounts are subject to VSP change.
Frames:
Frames Allowance $150 Retail allowance
Contact Lenses in lieu of eye glasses, materials only:
Frequency Every 12 Months

Lens Allowance $150 Retail allowance
Please note: This summary 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.

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