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Superior Vision New Product Flyer.Pub NEW WHIT PRODUCT– SUPERIOR VISION Vision Plans offered by Superior Vision: 20 Years in Business AM Best Rating* A- Strength of the national Vision Network 48,000 providers nationwide Optometrists Ophthalmologists Opticians and Optical Chains Major Chain Stores Listed Below, but not limited to, please see website for full provider directory. America’s Best Contacts LensCrafters Taylor SVS Vision and Eyeglasses Nationwide Vision Crown Optical Schaeffer Eye Center Cohen's Fashion Optical Pearle Vision Dr. Tavel’s Family Eye Site for Sore Eyes Doctor’s Vision Center Sam’s Club Optical Care Texas State Optical Eyeglass World Sears Optical Eye Care Associates Today’s Vision Eyeland Shopko Vision Eyecarecenter VisionFirst EyeMart Express Sterling Optical Longe Optical Vision Source EyeMasters Target Optical Master Eye Associates Visionworks For Eyes Optical Berkeley Eye Center Midwest Vision Centers Costco (Eff. 1/1/14) JCPenney Optical Campbell Cunningham & H. Rubin Vision Centers Online Contact Lenses at www.svcontacts.com 30% discount off retail (all major brands and types of contact lenses) Contacts delivered directly to home address Incremental orders (may use allowance all year long) Vision ~ A Free Wellness Component ~ SmartAlert For more information please visit: www.superiorvision.com In Network Plan 1 Plan 1 Materials Only Exam Copay $20 No benefit Exam Frequency 12 months No benefit Material Copay $0 $20 Lense Frequency 12 months 12 months Single paid in full paid in full Bifocal paid in full paid in full Trifocal paid in full paid in full Progressive trifocalallowance trifocalallowance Lenticular paid in full paid in full Frames Allowance $125 allowance $125 allowance Frames Frequency 24 months 24 months Contact Lens Fitting-Copay $25 $25 Contact Lenses $120 allowance $120 allowance Contact Lens Frequency 12 months 12 months Employee Only $6.68 $4.42 Employee / Spouse $13.22 $8.72 Employee / Children $12.96 $8.56 Employee / Family $19.72 $13.00 In Network Plan 2 Plan 2 (Materials Only) Exam Copay $20 No benefit Exam Frequency 24 months No benefit Material Copay $0 $20 Lense Frequency 24 months 24 months Single paid in full paid in full Bifocal paid in full paid in full Trifocal paid in full paid in full Progressive trifocalallowance trifocalallowance Lenticular paid in full paid in full Frames Allowance $125 allowance $125 allowance Frames Frequency 24 months 24 months Contact Lens Fitting-Copay $25 $25 Contact Lenses $120 allowance $120 allowance Contact Lens Frequency 24 months 24 months Employee Only $5.20 $3.46 Employee / Spouse $10.28 $6.84 Employee / Children $10.08 $6.70 Employee / Family $15.32 $10.20 In Network Plan 3 Plan 3 (Materials Only) Exam Copay $25 No benefit Exam Frequency 24 months No benefit Material Copay $25 $25 Lense Frequency 24 months 24 months Single paid in full paid in full Bifocal paid in full paid in full Trifocal paid in full paid in full Progressive trifocalallowance trifocalallowance Lenticular paid in full paid in full Frames Allowance $125 allowance $125 allowance Frames Frequency 24 months 24 months Contact Lens Fitting-Copay $25 $25 Contact Lenses $120 allowance $120 allowance Contact Lens Frequency 24 months 24 months Employee Only $4.14 $3.30 Employee / Spouse $8.18 $6.54 Employee / Children $8.02 $6.40 Employee / Family $12.20 $9.74 Factory scratch coating, ultraviolet coating, plastic tints, solid or gradients, and anti- reflective coating covered in full when utilizing an in network provider. Materials copay applies to lenses and frames only, not contact lenses. Standard Contact Lens Fitting applies to a current contact lens user who wears disposable, daily wear, or extended wear lenses only. Specialty Contact Lens Fitting applies to new contact wearers and/or a member who wears toric, gas permeable, or multi-focal lenses. Covered to the provider's retail amount for a standard lined trifocal lens; member pays the difference between the retail price of the progressive lens they have chosen and their provider's standard lined trifocal lens, plus applicable co-pay. Contact lenses are in lieu of eyeglass lenses and frames benefit. Out-of-Network Providers Non-Network Providers Superior Vision Pays $37 Opthalmologist / Exam $28 Optomistrist Lenses Single $35 Bifocal $50 Trifocal $60 Lenticular $95 Progressives $60 Frames $61 Contacts Elective $100 Medically Necessary $210.
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