Page 19 - Levelland 2024 Benefit Guide
P. 19

Vision Option:


          Guardian (VSP Choice Network)





                  Rate Information
                      24 Pay Period                                   Dependent Information
                                                          SkyBlue  Healthcare  offers  our  employees  the
           Employee Only                $  4.29
                                                          opportunity  to  cover  their  spouse  or  dependent
           Employee + Spouse            $  6.86           children. Children can join or remain on a parent’s
                                                          vision plan until age 26. When a child turns 26, they
           Employee + Child(ren)        $  7.01           will lose vision coverage on the last day of their birth
                                                          month. This is an automated process.
           Employee + Family            $11.30





         Benefits                                                      (In-Network) Plan Coverage


         Copays:
           Exam                                                                     $10 Copay

           Materials                                                                $25 Copay
           Standard Contact Fit                                               15% Off Professional Fee
         Frequency: (Based on Date of Service)
           Exams                                                                  Every 12 Months
           Lenses                                                                 Every 12 Months
           Frames                                                                 Every 24 Months
           Contact Lenses                                                         Every 12 Months
         Standard Lenses:

           Single Vision                                                     Covered in Full after Copay
           Lined Bifocal                                                     Covered in Full after Copay
           Lined Trifocal                                                    Covered in Full after Copay
           Frames:
           Frames Allowance / $0 Copay                                  $130 Retail allowance, 20% off Balance

         Contact Lenses in lieu of eye glasses, materials only:
           Frequency                                                              Every 12 Months
           Fitting and Evaluation Allowance                                         See Above

           Lens Allowance / $0 Copay                                           $130 Retail allowance

                       NOTE: This is only a brief overview. Please see Benefit Summary and policy for more details.

                  Website: https://www.guardianlife.com/contact-us  or Customer Service: VSP: 1-877-814-8970




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