Page 14 - 2024 FINAL Citizens Bank Benefit Guide

Vision Option:

VSP (Signature Network)

Per Pay Period

Dependent Information
Employee Only $ 6.07
Citizens Bank of Ada offers employees the opportunity to cover their
Employee + Spouse $ 9.70 spouse and dependent children. Children can join or remain on a

Employee + Child(ren) $ 9.91 parent’s vision plan until age 26. When a child turns 26, they will lose
vision coverage on the last day of their birth month.
Employee + Family $15.97

Benefits (In-Network) Plan Coverage
Copays:

Exam $20 Copay
Prescription Glasses $20 Copay
Frequency:

Exams Every 12 Months
Lenses Every 12 Months
Frames Every 24 Months
Eyewear Protection Program ( First 12 Months) Included at NO cost at PREMIER PROGRAM Providers

Standard Lens:
Single vision, Lined Bifocal and Trifocal Covered in Full

Polycarbonate Lenses for children Covered in Full
Standard Progressive Lens Covered in Full
Premium Progressive Lens Additional $80—$90 Copay

Custom Progressive Lens Additional $120—$160 Copay
Other Lens Enhancements 40% Average Savings
Frames:
$150 Frame Allowance / $170 for Featured Frames
Frames Allowance
20% savings on the amount over your allowance
Contact Lenses in lieu of eye glasses:

Frequency Every 12 Months
Standard or Premium Contact Exam & Fitting Up to $60 Copay

Contacts Allowance $130 Retail Allowance

NOTE: This is only a brief overview. Please see Benefit Summary for more details.
Website: www.vsp.com or Customer Service: 800-877-7195

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