Page 13 - Allegacy 2019 Benefit Guide Part Time

Voluntary Vision Benefits

Policy# 28185

Superior Vision
Voluntary Vision
Non-network
Network Provider Provider
Copays:

Eye Exam (Ophthalmologist) $15 Up to $44
Eye Exam (Optometrist) $15 Up to $39
Materials $25 See Below
Frequency of Services:
Eye Exam Every 12 months
Lenses Every 12 months
Frames Every 12 months
Contact Lenses Every 12 months
Materials Benefits:
Single Vision Up to $34
Bifocal Lenses Up to $48
Trifocal Lenses Covered in Full Up to $64
Lenticular Lenses Up to $88
Frames** Up to $125 Up to $64

Elective Contact Lenses (Professional Up to $120 Up to $100
Fees & Materials)
Medically Necessary Contact Lenses
*(Professional Fees & Materials) Covered in Full Up to $210

*Contact lenses are in lieu of eyeglass lenses and frames
** The member is responsible for paying any charges in excess of this allowance
 If out of network provider is used, member must pay the provider in full, and then file for reimbursement
from Superior Vision.
 Members pay 20% off retail for lens options and upgrades (scratch coat, UV coat, Anti-reflective coat, High
Index, Polycarbonate, tints).

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