Page 15 - Benefit Guide_SIPS_2020_Revised 2-12-21

Vision Option:

Humana 160

2019 Rate Information

Per Pay Period Bi-Weekly Weekly

Employee Only $4.20 $2.10 Dependent Information
SIPS Consults, Corp offers employees the opportunity
Employee + Spouse $8.41 $4.20
to cover their spouses and dependent children.
Employee + Child(ren) $7.99 $3.99 Children can join or remain on a parent’s vision plan
until age 26. When a child turns 26, they will lose vision
Employee + Family $12.55 $6.28 coverage on the last day of their birth month.

Benefits In-Network Coverage

Copays:
Exam $10 Copay

Materials $10 Copay
Contact Fitting (Standard) $0 Copay
Frequency:
Exams Every 12 Months

Lens Every 12 Months
Frames Every 24 months
Standard Plastic Lens:
Single Vision Covered in Full after Copay
Lined Bifocal Covered in Full after Copay
Lined Trifocal Covered in Full after Copay

Progressive Lens (standard) $10 Copay added to Bifocal Cost
Scratch Resistant, UV Coating and Tints $15 Copay
Photochromatic / Plastic Transitions $75 Copay
Frames:

Frames Allowance $160 Retail allowance
Contact Lenses in lieu of eye glasses, materials only:
Frequency Every 12 Months

Lens Allowance $160 Retail allowance 20% after $160
Frequency limitations are based on date of last service and not on calendar year.

NOTE: This is only is only a brief overview. Please see Benefit Summary more details.
Website: www.humana.com or Customer Service : 844-330-7799
15