Page 13 - Benefit Guide_Heritage School 2020_Revised 9-25-2020

Vision Option:

Humana

2020 Rate Information

Per Monthly Pay Period Dependent Information

Employee Only $10.72 We offer our employees the opportunity to cover their
spouses and dependent children. Children can join or
Employee + Spouse $21.44 remain on a parent’s vision plan until age 26. When a
child turns 26, they will lose vision coverage on the last
Employee + Child(ren) $20.36 day of their birth month.
Employee + Family $32.00

Frequency limitations are based on date of last service and not on calendar year.

Benefits—Vision 160 Plan In-Network Coverage

Copays:
Exam $10 Copay

Materials $10 Copay
Standard Contact Fitting No Charge
Frequency:
Exams Every 12 Months

Lens Every 12 Months
Frames Every 12 months

Standard Lens:
Single Vision Covered in Full after Copay
Lined Bifocal Covered in Full after Copay
Lined Trifocal Covered in Full after Copay

Standard Progressive Add on to Bifocal Copay + $10
Scratch Resistant, UV Coating and Tints Covered in Full after $15 Copay

Frames:
Frames Allowance $160 Retail allowance + 20% off overage
Contact Lenses in lieu of eye glasses, materials only:

Frequency Every 12 Months
Lens Allowance $160 Retail allowance + 15% off overage

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

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