Page 9 - 2022 OCFJSD Benefits Guide

Vision Plan

The district provides the opportunity for all staff members to obtain vision
insurance if they choose. Staff members pay the full cost of the premium
through payroll deduction and must enroll within 30 days of employment or
undergo evidence of insurability.

Your voluntary vision plan is provided through Delta Dental of Wisconsin

Benefit In-Network Out-of-Network

Exam $10 copay $35

Hardware $10 copay See below

Frequency

Exam
Every 12 months Every 12 months
• Lenses
• Frames
Frames $130 allowance, then
• One every 24 20% off balance $65
months
Lenses
Single vision lenses $10 $25
Bifocal lenses $10 $40
Trifocal lenses $10 $55

Medically necessary Paid in full $200
contact lenses

Elective contact lenses $120 allowance, then $96
in lieu of glasses 15% off balance

EMPLOYEE COST

Coverage Type Monthly Cost
Employee $6.09
Employee & Spouse $12.17
Employee & Children $12.42
Employee, Spouse & Children $18.51

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