Page 21 - Revelations - GROUP 1 Greenbrier 2021 Benefit Guide (R2)

Vision Option:

Mutual of Omaha

Rate Information
24 Pay Periods Dependent Information

Employee Only $ 3.53 Revelations Health Care Group offers our employees
the opportunity to cover their spouse or dependent
Employee + Spouse $ 6.70 children. Children can join or remain on a parent’s

vision plan until age 26. When a child turns 26, they will
Employee + Child(ren) $ 7.86
lose vision coverage on the last day of their birth
Employee + Family $11.05 month. This is an automated process.

Benefits (In-Network) Plan Coverage

Copays:

Exam $10 Copay
Materials $25 Copay
Standard Contact Fit Up to $40 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 Lenses $65 Copay added to Bifocal Copay
Scratch Resistant Coating Covered in Full after Copay
UV Treatment Covered in Full after Copay
Tint Covered in Full after Copay
Frames:

Frames Allowance / $0 Copay $130 Retail allowance, 15% off Balance
Contact Lenses in lieu of eye glasses, materials only:
Frequency Every 12 Months

Fitting and Evaluation Allowance See Above
Lens Allowance / $0 Copay $130 Retail allowance

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