Page 14 - 2022 Coral LTC - Heritage Oaks Benefit Guide Effective 7-1-22

Vision Option:

Mutual of Omaha

Rate Information
24 Pay Period Dependent Information

Employee Only $ 3.35 We offer our employees the opportunity to cover their
spouse or dependent children. Children can join or re-
Employee + Spouse $ 6.28
main on a parent’s vision plan until age 26. When a
Employee + Child(ren) $ 7.39 child turns 26, they will lose vision coverage on the last
day of their birth month. This is an automated process.
Employee + Family $10.35

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 $25 Copay

Lined Bifocal $25 Copay
Lined Trifocal $25 Copay
Progressive Lenses $65 Copay added to Bifocal Copay
Scratch Resistant Coating $0 Copay
UV Treatment $0 Copay
Tint $0 Copay
Frames:

Frames Allowance / $0 Copay $130 allowance, plus 20% off Balance over
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 allowance, plus 15% off Balance over

14