Page 15 - 2023 Heritage School Benefit Guide
P. 15
Vision Option:
Humana
2023 Rate Information
Per Monthly Pay Period Dependent Information
Employee Only $11.37 We offer our employees the opportunity to cover their
spouses and dependent children. Children can join or
Employee + Spouse $22.74 remain on a parent’s vision plan until age 26. When a
child turns 26, they will lose vision coverage on the last
Employee + Child(ren) $21.60 day of their birth month.
Employee + Family $33.95
Frequency limitations are based on date of last service and not on calendar year.
Benefits—Vision 160 Plan In-Network Coverage
Copays:
Exam $10 Copay
Materials $10 Copay
Standard Contact Fitting No Charge
Frequency:
Exams Every 12 Months
Lens Every 12 Months
Frames Every 12 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 + $10
Scratch Resistant, UV Coating and Tints Covered in Full after $15 Copay
Frames:
Frames Allowance $160 Retail allowance + 20% off overage
Contact Lenses in lieu of eye glasses, materials only:
Frequency Every 12 Months
Lens Allowance $160 Retail allowance + 15% off overage
Please note: This 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.
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