Page 7 - 2015 Saint Louis University Benefits Guide
P. 7
Saint Louis University
Vision Plan
In-Network (Choice Network) Out-of-Network
Wellvision Exam $10 copay Up to $45 allowance
Lenses
Single $10 copay Up to $30 allowance
Bifocal $10 copay Up to $50 allowance
Trifocal $10 copay Up to $65 allowance
Frames
$150 allowance for a wide selection of frames; $170 allowance Up to $70 allowance
for featured frame brands; 20% on the amount over your
balance
Contacts
$150 allowance for contacts; including the contacts lens exam Up to $105 allowance
(itting and evaluation)
Frequency
Exam Every calendar year
Lenses Every calendar year
Contacts Every calendar year
Frames Every other calendar year
Accident Plan
Please note the below is a high level overview of the plan design. Additional beneits are available under the
policy.
Service Beneit Amount
Accident Hospital Care
Surgery (open abdominal, thoracic) $1,200
Hospital Coninement $250/day up to 365 days
Follow-Up Care
Medical Equipment $120
Physical Therapy $30/treatment (six max)
Prosthetic Device $600 (one)/$1,200 (two or more)
Emergency Care
Ground Ambulance Transport $120
Emergency Room Treatment $180
Common Injuries—Dislocations Closed Reduction/Open Reduction*
Hip Joint $2,400/$4,800
Knee $1,200/$2,400
Shoulder $360/$720
Common Injuries—Fractures Closed Reduction/Open Reduction
Hip $1,800/$3,600
Leg $960/$1,920
Ankle $360/$720
Nose $120/$240
Wellness Beneit** $100
* Closed Reduction is non-surgical reductions of a completely separated joint. Open Reduction is surgical reduction of a completely separated joint
** The covered employee will receive a single standard annual beneit of $100 for each covered employee and spouse who completes a health
screening test. The standard child beneit is 50% of the employee beneit amount, with a maximum of $200 in child beneits payable per calendar
year.
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Vision Plan
In-Network (Choice Network) Out-of-Network
Wellvision Exam $10 copay Up to $45 allowance
Lenses
Single $10 copay Up to $30 allowance
Bifocal $10 copay Up to $50 allowance
Trifocal $10 copay Up to $65 allowance
Frames
$150 allowance for a wide selection of frames; $170 allowance Up to $70 allowance
for featured frame brands; 20% on the amount over your
balance
Contacts
$150 allowance for contacts; including the contacts lens exam Up to $105 allowance
(itting and evaluation)
Frequency
Exam Every calendar year
Lenses Every calendar year
Contacts Every calendar year
Frames Every other calendar year
Accident Plan
Please note the below is a high level overview of the plan design. Additional beneits are available under the
policy.
Service Beneit Amount
Accident Hospital Care
Surgery (open abdominal, thoracic) $1,200
Hospital Coninement $250/day up to 365 days
Follow-Up Care
Medical Equipment $120
Physical Therapy $30/treatment (six max)
Prosthetic Device $600 (one)/$1,200 (two or more)
Emergency Care
Ground Ambulance Transport $120
Emergency Room Treatment $180
Common Injuries—Dislocations Closed Reduction/Open Reduction*
Hip Joint $2,400/$4,800
Knee $1,200/$2,400
Shoulder $360/$720
Common Injuries—Fractures Closed Reduction/Open Reduction
Hip $1,800/$3,600
Leg $960/$1,920
Ankle $360/$720
Nose $120/$240
Wellness Beneit** $100
* Closed Reduction is non-surgical reductions of a completely separated joint. Open Reduction is surgical reduction of a completely separated joint
** The covered employee will receive a single standard annual beneit of $100 for each covered employee and spouse who completes a health
screening test. The standard child beneit is 50% of the employee beneit amount, with a maximum of $200 in child beneits payable per calendar
year.
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