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

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

until age 26. When a child turns 26, they will lose vision
Employee + Family $2.33 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.
11