Page 10 - Affinity Neurocare Benefit Guide 2022 updated

Vision Option:

Superior Vision

Per Pay Period Bi-weekly Dependent Information
Employee Only $ 0.00 We offer our full-time employees and their eligible dependents
Employee + Spouse $ 3.60 vision benefits. Children can join or remain on a parent’s vision

Employee + Child(ren) $ 4.67 plan until age 26. When a child turns 26, they will lose vision
coverage on the last day of their birth month.
Employee + Family $ 9.14

Benefits Highlights Plan Coverage (In-Network) / (Out)

Copays: In / Out of network copays

Exam (Ophthalmologist or Optometrist) $10 / up to $35
Materials $25 / up to $70
Formulary Contact Lens (Fitting/evaluation fees) $175 / Please see plan details

Frequency:
Exams Every 12 Months
Lens / Contact Lens Fitting Every 12 Months
Frames Every 12 Months

Frequency is based On 1st Date of Service starts your 12 months
Standard Lens:
Single Vision Please look at the plan details online or on the app

Lined Bifocal Please look at the plan details online or on the app
Lined Trifocal Please look at the plan details online or on the app

Progressive Lens (Cost is Based on Tiers) Please look at the plan details online or on the app
Standard Scratch –resistant Coating Please look at the plan details online or on the app

Tints Please look at the plan details online or on the app
Ultraviolet Coat Please look at the plan details online or on the app
Other Lens Options Please look at the plan details online or on the app

Frames:
Frames Allowance $150 Retail Allowance / up to $70 out of network

Contact Lenses in lieu of eye glasses, materials only:
Frequency Every 12 Months

NOTE: This is only is only a brief overview. Please see Benefit Summary more details.
Website: www.supervision.com or Customer Service : (800) 507-3800
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