Page 22 - Pampa 4-1-2024 Benefit Guide

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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