Page 19 - Pampa 2024 Benefit Guide

Vision Option:

Guardian (VSP Choice Network)

Rate Information
24 Pay Period Dependent Information
SkyBlue Healthcare offers our employees the
Employee Only $ 4.29
opportunity to cover their spouse or dependent
Employee + Spouse $ 6.86 children. Children can join or remain on a parent’s
vision plan until age 26. When a child turns 26, they
Employee + Child(ren) $ 7.01 will lose vision coverage on the last day of their birth
month. This is an automated process.
Employee + Family $11.30

Benefits (In-Network) Plan Coverage

Copays:
Exam $10 Copay

Materials $25 Copay
Standard Contact Fit 15% Off Professional Fee
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
Frames:
Frames Allowance / $0 Copay $130 Retail allowance, 20% 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

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

Website: https://www.guardianlife.com/contact-us or Customer Service: VSP: 1-877-814-8970

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