Page 12 - 2024-25 Gas Clip Technologies Benefit Guide EXECUTIVES

Vision Option:

Equitable

2024-25 Rate Information

Per Pay Period Semi-Monthly
Dependent Information
Employee Only $0.69
Gas Clip Technologies offers employees the oppor-
Employee + Spouse $1.38 tunity to cover their spouses and dependent children.
Children can join or remain on a parent’s vision plan
Employee + Child(ren) $1.48 until age 26. When a child turns 26, they will lose vision

coverage on the last day of their birth month.
Employee + Family $2.33

Frequency limitations are based on date of last service and not on calendar year.

Benefits — Vision In-Network Coverage
Copays:
Exam $10 Copay

Materials $25 Copay
Standard Contact Fitting Up to $60
Frequency:

Exams Every 12 Months
Lens Every 12 Months
Frames Every 24 months
Standard Plastic Lens:

Single Vision Covered in Full after $25 Copay
Lined Bifocal Covered in Full after $25 Copay

Lined Trifocal Covered in Full after $25 Copay
Lenticular Covered in Full after $25 Copay
Standard Progressive $55 Copay

Scratch Resistant $33 Copay *Discounts are subject to VSP change.
UV Coating $16 Copay *Discounts are subject to VSP change.
Frames:
Frames Allowance $150 Retail allowance
Contact Lenses in lieu of eye glasses, materials only:
Frequency Every 12 Months

Lens Allowance $150 Retail allowance
Please note: This summary 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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