Page 22 - 2022 Benefit Guide Oasis at Austin

Vision Option:

Mutual of Omaha

Rate Information
26 Pay Period Dependent Information

Employee Only $3.09 Revelations Health Care Group offers our employees
the opportunity to cover their spouse or dependent
Employee + Spouse $5.79
children. Children can join or remain on a parent’s
Employee + Child(ren) $6.82 vision plan until age 26. When a child turns 26, they will
lose vision coverage on the last day of their birth
Employee + Family $9.55 month. This is an automated process.

Benefits (In-Network) Plan Coverage

Copays:

Exam $10 Copay
Materials (Lens and Frames) $25 Copay
Standard Contact Fit & Follow Up 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 Plastic 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
Additional Pairs of Glasses Up to 40% Discount
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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