Page 10 - Letterpress 2021 Benefit Guide (REVISED)

Vision Option:

Superior Vision

2021 Rate Per Period

Dependent Information
Employee Only $ 3.12
Letterpress Graphics, Inc. offers employees the opportunity
Employee + Spouse $ 6.24 to cover their dependent children. Children can join or
remain on a parent’s vision plan until age 26.
Employee + Child(ren) $ 7.11
When a child turns 26, they will lose vision coverage on the

Employee + Family $ 10.98 last day of their birth month.

Benefits (In-Network) Plan Coverage

Copays:

Exam $10 Copay
Materials (Frames) $25 copay
Contact Lens Fitting (Standard) $25 Copay
Contact Lens Fitting (Specialty) $25 Copay Up To $50 Retail Allowance

Frequency: Frequency is based on date of service
Exams Every 12 Months
Lens Every 12 Months
Frames Every 24 months
Standard Lenses:
Single Vision Covered in Full after Copay

Lined Bifocal Covered in Full after Copay
Lined Trifocal Covered in Full after Copay
Progressive Lens (Standard Lenses) Covered in Full after Copay
Scratch Resistant Up to $13 Copay
UV Coating Up to $15 Copay
Tints, solid or gradients Up to $25 Copay

Frames:
Frames Allowance $130 Retail Allowance
Contact Lenses in lieu of eye glasses, materials
only:
Frequency Every 12 Months
Lens Allowance $120 Retail Allowance

NOTE: This is only a brief overview. Please see Benefit Summary more details.
Website: www.superiorvision.com or Customer Service : 800-507-3800

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