Page 11 - NTNSC_Benefit Guide 2021
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Vision Option:
Humana
2021 Rate - Per Pay Period
Dependent Information
Per Pay Period Humana North Texas Neuroscience and Sleep Center, P.A.
covers employees and offers employees the
Employee Only $0.00
opportunity to cover their eligible dependents.
Employee + Spouse $3.06
Children can join or remain on a parent’s vision plan until
Employee + Child(ren) $2.75 age 26. They will lose their coverage on the last day of
their birth month.
Employee + Family $6.07
Benefits (In-Network) Plan Coverage
Copays:
Exam $10 Copay
Materials $15 Copay
Standard Contact Lens Fittings and Follow Up Up to $40 Copay
Frequency:
Exams Every 12 Months
Lens Every 12 Months
Frames Every 24 months
Standard Lens:
Single Vision Covered in Full after Copay
Lined Bifocal Covered in Full after Copay
Lined Trifocal Covered in Full after Copay
Standard Progressive Add on to Bifocal Copay + $15
Scratch Resistant, UV Coating and Tints Covered in Full after $15 Copay
Frames:
Frames Allowance $130 Retail allowance with 20% Discount of Balance
Contact Lenses in lieu of eye glasses:
Frequency Every 12 Months
Lens Allowance $130 Retail allowance with 15% Discount of Balance
Please note: This is intended for general information purposes.
It is not a guarantee of benefits. Please reference the Summary of Benefits or contact the carrier for specific details.
Website: www.humana.com Customer Service: 1-866-995-9316
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