Page 18 - Benefit Guide Stamford Residence and Rehab
P. 18
Vision Option:
Superior Vision
2020/2021 Rate Information
26 Dependent Information
Bi-Weekly Stamford Residence and Rehabilitation Centeroffers
employees the opportunity to cover their spouse or
Employee Only $ 3.52
dependent children. Children can join or remain on
Employee + Spouse $ 7.05 a parent’s vision plan until age 26.
When a child turns 26, they will lose vision coverage
Employee + Child(ren) $ 8.02 on the last day of their birth month. This is an
automated process.
Employee + Family $12.38
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.
18
