Page 12 - Citizens Bank Benefit Guide 2020_Revised 12-11-2020

Vision Option:

VSP (Signature Network)

Per Pay Period
Dependent Information
Employee Only $ 6.08
Citizens Bank of Ada offers employees the opportunity to cover their
Employee + Spouse $ 9.73 spouse and dependent children. Children can join or remain on a

Employee + Child(ren) $ 9.93 parent’s vision plan until age 26. When a child turns 26, they will lose
vision coverage on the last day of their birth month.
Employee + Family $16.01

Benefits (In-Network) Plan Coverage

Copays:
Exam $20 Copay
Materials $20 Copay

Frequency:
Exams Every 12 Months
Lens Every 12 Months
Frames Every 24 Months

Eyewear Protection Program ( First 12 Months) Included at NO cost at PREMIER PROGRAM Providers
Standard Lens:
Single, Lined Bifocal and Trifocal Covered in Full

Polycarbonate Lenses for children Covered in Full
Standard Progressive Lens Covered in Full

Premium Progressive Lens Additional $80—$90 Copay
Custom Progressive Lens Additional $120—$160 Copay
Solid Tints and Dyes (Pink I & II) Covered in Full / Except Pink I & II $13 Copay
Plastic Gradient Dye $15 Copay

UV Protection $14 Copay
Anti-reflective Coating Single Vision $23 Copay / Multifocal $28 Copay

Other Lens Enhancements 35 to 40% Average Savings
Frames:
Frames Allowance $150 Wide Selection / $170 Featured Frames

Contact Lenses in lieu of eye glasses:

Frequency Every 12 Months
Standard or Premium Contact Exam & Fitting Up to $60 Copay

Lens Allowance $130 Retail Allowance

NOTE: This is only a brief overview. Please see Benefit Summary for more details.
Website: www.vsp.com or Customer Service: 800-877-7195
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