Page 13 - Summit Group 2 Benefits Eff 12-1-19

Vision Option:

Superior Vision

Rate Information
Per Pay Period Dependent Information

Employee Only $ 3.37 Summit LTC Management, LLC offers our employees
the opportunity to cover their spouse or dependent
Employee + Spouse $ 6.73 children. Children can join or remain on a parent’s

vision plan until age 26. When a child turns 26, they
Employee + Child(ren) $ 7.64
will lose vision coverage on the last day of their birth
Employee + Family $11.80 month. This is an automated process.

Benefits (In-Network) Plan Coverage

Copays:
Exam $10 Copay

Materials $20 Copay
Frequency: (Based on Date of Service)
Exams Every 12 Months
Lenses Every 12 Months
Frames Every 12 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 Lenses Covered in Full after Copay (up to Trifocal Lens Amount)
Scratch Resistant Coating, UV Coating and Tints Covered in Full after Copay

Frames:
Frames Allowance $130 Retail allowance
Contact Lenses in lieu of eye glasses, materials only:

Frequency Every 12 Months
Lens Allowance $130 Retail allowance

NOTE: This is only a brief overview. Please see Benefit Summary for more details.

Website: www.superiorvision.com or Customer Service : 800-507-3800

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