Page 11 - RS&A Benefits Enrollments Guide

Voluntary Vision Benefits

Superior Vision
Voluntary Vision

Group# 30106
Copays:
Eye Exam $10
Materials $25
Contact Lens Fitting (Standard &
Specialty) $25
Frequency of Services (based on date of service):
Eye Exam Once per 12 months
Frames Once per 24 months
Contact Lens Fitting Once per 12 months
Lenses Once per 12 months
Contact Lenses Once per 12 months
Benefits: In-Network Out-of-Network
Contact Lens Fitting (Standard) Covered in Full after Copay Not covered
Contact Lens Fitting (Specialty) $50 retail allowance Not covered

Single Vision Covered in Full after Copay Up to $34 retail
Bifocal Lenses Covered in Full after Copay Up to $48 retail
Trifocal Lenses Covered in Full after Copay Up to $64 retail
Lenticular Lenses Covered in Full after Copay Up to $88 retail
Frames $125 retail allowance Up to $64 retail
Elective Contact Lenses* $120 retail allowance Up to $100 retail
(Professional Fees & Materials)
*Contact lenses are in lieu of eyeglass lenses and frames benefit.
Discounts on Covered Materials:
Frames: 20% off amount over allowance
Lens options: 20% off retail
Progressives: 20% off amount over standard progressive retail

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