Page 22 - Pampa Benefit Guide 4-1-24
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Vision Option:


          Principal Life Insurance (VSP)






                                                                         Dependent Information

                                                               SkyBlue  Healthcare  offers  our  employees  the
                     Semi Monthly           Principal VSP
                    24 Pay Periods             Vision          opportunity to cover their spouse or dependent
                                                               children.  Children  can  join  or  remain  on  a
            Employee Only                      $ 3.65          parent’s    vision plan until age 26. When a child
                                                               turns  26,  they  will  lose  vision  coverage  on  the
            Employee + Spouse                  $ 6.47
                                                               last day of their birth month. This is an automat-
            Employee + Child(ren)              $ 7.38          ed process.

            Employee + Family                  $10.93


         Benefits                                                      (In-Network) Plan Coverage


         Copays:
           Exam                                                                     $10 Copay

           Materials                                                                $25 Copay
           Contacts (standard)                                                    Up to $60 Copay
         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
         Progressive (standard) Lenses:                                      Covered in Full after Copay
           Frames:
           Frames Allowance / $0 Copay                                  $150 Retail allowance, 20% off Balance
         Contact Lenses in lieu of eye glasses, materials only:

           Frequency                                                              Every 12 Months
           Fitting and Evaluation Allowance                                       Up to $60 Copay

           Lens Allowance / $0 Copay                                           $150 Retail allowance
                       NOTE: This is only a brief overview. Please see Benefit Summary and policy for more details.

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


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