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Vision Option:

Superior Vision

Rate Information
Dependent Information
Per Pay Period Semi-Monthly Monthly
Summit LTC Management, LLC offers our
Employee Only $ 3.37 $ 6.73 employees the opportunity to cover their
spouse or dependent children. Children
Employee + Spouse $ 6.73 $ 13.45 can join or remain on a parent’s vision

plan until age 26. When a child turns 26,
Employee + Child(ren) $ 7.64 $ 15.27
they will lose vision coverage on the last
Employee + Family $ 11.80 $ 23.59 day of their birth month. This is an automat-
ed process.

Benefits (In-Network) Plan Coverage

Copays:
Exam $10 Copay

Materials $20 Copay
Frequency: (Based on Date of Service)
Exams Every 12 Months
Lenses Every 12 Months
Frames Every 12 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 Covered in Full after Copay (up to Trifocal Lens Amount)
Scratch Resistant Coating, UV Coating and Tints Covered in Full after Copay

Frames:
Frames Allowance $130 Retail allowance
Contact Lenses in lieu of eye glasses, materials only:

Frequency Every 12 Months
Lens Allowance $130 Retail allowance

NOTE: This is only a brief overview. Please see Benefit Summary for more details.

Website: www.superiorvision.com or Customer Service : 800-507-3800

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