Page 19 - Phil Chai - Benefit Guide Queen Sweet Jane revised 091621

Vision Option:

Superior Vision

Rate Per Pay Period

Dependent Information
Employee Only $ 3.52
Queen Sweet Jane, LLC offers employees the
Employee + Spouse $ 7.05 opportunity to cover their spouse or dependent
children. Children can join or remain on a
Employee + Child(ren) $ 8.02 parent’s vision plan until age 26.

Employee + Family $12.38 When a child turns 26, they will lose vision cover-
age on the last day of their birth month. This is an
automated process.

Benefits (In-Network) Plan Coverage

Copays:
Exam $10 Copay

Materials $25 copay
Fitting Copay (Standard) $25 Copay
Frequency:
Based on date of service
Exams Every 12 Months

Lens Every 12 Months
Frames Every 24 months
Standard Lens:
Single Vision Covered in Full

Lined Bifocal Covered in Full
Lined Trifocal Covered in Full
Standard Progressive Lens Covered at Lined Trifocal Level
Scratch, UV coat Covered in Full
Frames:

Allowance $150 retail allowance
Contact Lenses in lieu of eye glasses,
materials only:
Frequency Every 12 Months

Contact Lens Allowance $150 retail allowance

Please note: This summary is intended for general information purposes.
It is not a guarantee of benefits. Please reference the SBC or contact the carrier for specific details.

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