Page 137 - 2018 Village Ordinance Book 122818
P. 137
Village of Sturtevant
Vision Proposal -May 1, 2018 Effective Date
Carrier Delta
DeltaVision - Alt 1
Plan Name
Full Plan - Access Network Pan A
Exam Copay In-Network Out-of-Network
Materials Copay
$0 $35
$0 N/A
Standard Lenses* $0 $25 allowance
Single Vision $0 $40 allowance
Bifocal $0 $55 allowance
Trifocal
50% of selected
Frames
$150 allowance, in-network
Contacts
Frequency 20% off balance allowance
Examination 80% of selected
Lenses or Contacts
Frames $150 allowance, in-network
15% off balance allowance
12 months 12 months
12 months 12 months
12 months 12 months
Employee Only 6 $9.68
Employee & Spouse 7 $19.36
Employee & Child(ren) 0 $19.76
Family 6 $29.44
Monthly Premium $538.40
Annual Premium $6,460.80
*Lens options such as anti-reflective coating, scratch-resistance,
The above summary is only a brief description of benefits, for a more detailed compariso
