Superior Vision Plan for Employees of Person County Schools

The Right Choice For Good Health and Sight

A Complete Provider Network

The Superior Vision provider network of ophthalmologists, optometrists and optical companies now number over 27,000 providers located throughout the U.S. The Superior Vision network not only brings to you one of the largest panels of ophthalmologists in the nation, but also one of the largest groupings of national and regional optical chain locations. See the providers near you in the Superior Vision provider directory or view a provider listing at www.superiorvision.com. If your current provider is not listed, you may nominate your provider for consideration to the Superior Vision network.

Vision Plan - Preferred Provider (PPO)/Indemnity - Outline of Benefits

12 Month Rates
Employee Only $9.90
Employee and One Dependent $19.22
Employee and Family $28.24

Copayment:

Gold Preferred plan Services/Frequency

*Contact lenses are in lieu of eyeglass lenses and frames benefit
** The insured is responsible for paying any charges in excess of this allowance
***Standard contact lens fitting fee applies to an existing contact lens user who wears disposable, daily wear, or extended wear lenses only. The specialty contact lens fitting fee applies to new contact lens wearers and/or a member who wears toric, gas permeable, or multi-focal lenses. For the specialty fit, the member is responsible for any charges over $50.
Benefits In-Network Out-of-Network
Comprehensive Exam Ophthalmologist (MD) Covered in Full Up to $44.00
Comprehensive Exam Optometrist (OD) Covered in Full Up to $39.00
Standard Lenses (Per Pair):
  • Single Vision
  • Bifocal
  • Trifocal
  • Lenticular
  • Covered in Full
  • Covered in Full
  • Covered in Full
  • Covered in Full
  • Up to $34.00
  • Up to $48.00
  • Up to $64.00
  • Up to $88.00
Contact Lenses (Per pair)*
Medically Necessary Covered in Ful Up to $210.00
Cosmetic-Elective** Up to $120.00 Up to $100.00
Standard Contact Lens Fitting Exam Fee***
Specialty Contact Lens Fitting Exam Fee***		 $35 Copay
$35 Copay		 Not Covered
Not Covered
Frames - Standard Up to $100.00 Up to $50.00

Discounts for Additional Materials:

Discounts are available for additional purchases of eyewear and contact lenses. Discounts are provided by Superior Vision Services contracted providers identified in the Provider Directory with a "DP". These discounts do not apply to the insured benefit plan underwritten by ReliaStar Life Insurance Company. Employees who elect coverage cannot change coverage until the open enrollment period after the first plan year, except for "coverage category" as a result of a qualifying family status change. Employees who do not elect coverage cannot enroll until the next open enrollment period. For further details refer to the master Policy on file with your Human Resources Department.

Limitations (options at additional cost)

The Superior Vision Plan is designed to provide your basic eyewear needs. It does not cover items that are considered cosmetic or elective. The following options will require an additional charge over the covered benefit. Pay any additional charges directly to your provider. Example: Standard design bifocal lenses are a covered benefit. Blended (no-line) bifocals will require an additional charge.

Exclusions (products & services not covered)

  1. Professional Services and/or Materials in conjunction with:
    • blended bifocals, no line, or progressive lenses
    • compensated or special multi-focal lenses
    • plain (non-prescription) lenses
    • anti-reflective, scratch, UV400 or any coating or lamination applied to lenses.
    • subnormal vision aids
    • tints other than solid
    • orthoptics, vision training and developmental vision procedures
    • polycarbonate lenses
  2. Medical or surgical treatment of the eyes
  3. Any eye examination or any corrective eyewear required by an Employer as a condition of employment
  4. Any injury or illness when covered under Workers' Compensation or similar law
  5. Plain or prescription sunglasses, no-line bifocals, blended lenses are not covered, an Insured may elect to apply the maximum allowance for standard lenses toward his or her cost of progressive lenses.
  6. Subnormal vision aids
  7. Services rendered or Materials purchased outside the U.S. or Canada, unless:
    • the Member resides in the U.S. or Canada; and
    • the charges are incurred while on a business or pleasure trip
  8. Charges in excess of the Usual, Customary and Reasonable charge for the Professional Service or Materials
  9. Experimental or non-conventional treatment or device
  10. Safety eyewear
  11. Spectacle lens styles, materials, treatments of "add-ons" not shown in the Benefits Summary
  12. Services or Materials rendered by a provider other than an Ophthalmologist, Optometrist or Optician acting within the scope of his or her license
  13. Any additional service required outside basic vision analysis for contact lenses, except fitting fees.
  14. Services rendered after the date an Insured ceases to be covered under this Certificate, except when vision Materials ordered before coverage ended are delivered and the services rendered to the Insured within 31 days from the date of such order.
  15. Services rendered or Materials ordered before the date of coverage began under this Certificate
  16. Regardless of Optical Necessity, benefits are not available more frequently than that which is specified in the Benefits Summary

Note: This is only a summary of the benefit plan. You may review and/or obtain a copy of the Master Policy and Certificate of Coverage by contacting your Human Resources/Employee Benefits Office.

Definitions of Contact Lenses

Contact Lenses, Elective/Cosmetic. Elective/Cosmetic contact lenses are those that are worn solely for cosmetic or convenience reasons. They are chosen because they are preferred over the wearing of conventional eyeglasses. Contact lenses covered by the Plan must contain a prescription for correcting a vision deficiency. Charges over the benefit allowance are paid directly to the provider.

Contact Lenses, Medically Necessary. These lenses must be specifically prescribed by the eye doctor to be used for the reason or reasons described below. Reimbursement for these lenses will be considered as payment-in-full when utilizing an in-network provider.

Note: The narrowing of visual fields due to high minus high plus corrections is not considered a reason for medically necessary contact lenses.

CONTACT LENS EXAM/FITTING FEE: Most providers charge a fee for the fitting of contact lenses. This fee is separate from the eye examination and will vary depending on the provider's fee structure policies. It will also vary due to circumstances or complexities involving the physiological condition of the eyes, the lens prescription, and they type of lenses used. The contact lens exam/fitting fee may be included in the contact lens allowance.

Refractive Surgery Discount Superior Vision Services, Inc. is contracting with ophthalmic refractive surgeons to provide SVS members with a 20% discount off their surgical fees for radial keratotomy (RK), photo-refractive keratotomy (PRK) and LASIK. Providers contracted are noted with a RF under their name in the SVS Provider Directory. This discount does not apply to the insured plan underwritten by ReliaStar Life Insurance Company.

Procedure when using a Superior Vision Plan in-network provider:

  1. Identify yourself to the in-network provider as a member of the Superior Vision Plan. You can use your I.D. card for this purpose or simply give the provider your name, employer name, and your social security number. The provider will call SVS Member Services to verify your eligibility and obtain an authorization number. The I/D. card provided to you can be used for all covered family members.
  2. After eligibility is established, and an authorization number is received by the provider, services will be rendered. There is nothing else that you need to do except pay the provider directly for any appropriate copayments and charges above the covered benefits. The in-network provider handles all claims and paperwork.

Procedure when using a non-network provider:

  1. To receive services from a non-network provider, it is important that you first call Superior Vision Services Member Service Department at 800-507-3800 to receive your own authorization number. By doing so, you can be assured of your eligibility and reimbursement for money spent.
  2. After receiving services and paying in-full for the examination and/or materials (you do not pay a copayment to the non-network provider), submit your original itemized billing received from the provider, along with your authorization number, to the SVS Claims Administration office listed below.
  3. You will be reimbursed according to the schedule of any allowances for non-network providers, less any required copayments.

Member Services Information: P.O. Box 967* Rancho Cordova, CA 9574
For Member Services & Claims Inquiry call 1-800-507-3800 - www.superiorvision.com
The Superior Vision Plan is underwritten by National Guardian Life Insurance Company. National Guardian Life Insurance Company is not affiliated with The Guardian Life Insurance Company of America, a/k/a The Guardian or Guardian Life

PLEASE NOTE: If an insured or dependent is allowed to elect to terminate this vision coverage, they will not be allowed to re-enroll in this vision program until the first day after the end of a twenty-four (24) month period immediately following their termination date.

Superior Vision Plan for Employees of Person County Schools
Materials Only Plan

OUTLINE OF BENEFITS - GOLD PREFERRED MATERIALS ONLY PLAN WITH MATERIALS DISCOUNT VISION PLAN - PREFERRED PROVIDER (PPO)/INDEMNITY

*Materials copayment only applies to lenses and frames, not contact lenses.
Copayments apply to in network benefit and are deducted from non network reimbursements.
COPAYMENT AMOUNT: $15.00 Materials* 12 Month Rates
EMPLOYEE ONLY $6.78
EMPLOYEE AND ONE DEPENDENT $13.18
EMPLOYEE AND FAMILY $19.32
*Contact lenses are in lieu of eyeglass lenses and frames benefit
**The insured is responsible for paying any charges in excess of this allowance.
***Standard contact lens fitting fee applies to an existing contact lens user who wears disposable, daily wear, or extended wear lenses only. The specialty contact lens fitting fee applies to new contact lens wearers and /or a member who toric, gas permeable, or multi-focal lenses. For the specialty fit, the member is responsible for any changes over $50.
SERVICES/FREQUENCY
Lenses
Frames
Contact Lenses		 12 Months
24 Months
12 Months
BENEFITS IN-NETWORK NON-NETWORK
Lenses (Standard) Per Pair:
  • Single Vision
  • Bifocal
  • Trifocal
  • Lenticular
  • Covered In Full
  • Covered In Full
  • Covered In Full
    • Covered In Full

  • Up to $34.00
  • Up to $48.00
  • Up to $64.00
  • Up to $88.00
Contact Lenses (Per Pair)*:
  • Medically Necessary
  • Cosmetic (Elective)**
  • Standard Contact Lens Fitting Exam Fee***
  • Specialty Contact Lens Fitting Exam Fee***
  • Covered In Full
  • Up to $120.00
  • $25 Copay
  • $25 Copay
  • Up to $210.00
  • Up to $100.00
  • Not Covered
  • Not Covered

MATERIALS SVP 8-20 DISCOUNT SCHEDULE:

Featured are 20% discounts on the provider's charges for upgrades to the 1st pair of covered eyeglass lenses. This includes tints, coatings, special materials and special lens designs. The member may also receive a 20% discount on the difference between the retail price of the frame they have selected, and their allowance, as shown on the benefit outline above.

Out of Pocket Maximums for Lens Add-Ons - Single Vision Lenses

Out of Pocket Maximums for Lens Add-Ons - Std Lined Bi & Trifocal Lenses

Also included are discounts on the purchases of additional pairs of eyeglasses and contact lenses. See the schedule below. These materials discounts are available from in-network providers who are identified in the directory with a "DP" (discount plan) associated with their listing as a service they provide at the location.

FRAMES - 30% OFF RETAIL

No restrictions apply

LENSES (Uncoated Plastic - CR39, or Glass) - 30% OFF RETAIL

Single Vision; Bifocal (FT 25-35 & Executive); Trifocal (FT 7X25, 7X28, 8X35 & Executive); Progressives; Zyl and Metal Mounting

ADD-ON TO BASE LENSES - 20% OFF RETAIL

Tints, Coatings, Colored Lenses; Power over 4.00D Sphere, 2.00D Cylinder & 5.00D Prism; Polycarbonate, High Index, Photochromatics; Cosmetic Finishing, Beveling, Edging & Mounting

EVERYDAY "FRAME AND LENS PACKAGE PRICING" - 20% OFF RETAIL

CONTACT LENSES - 20% OFF RETAIL

DISPOSABLE CONTACT LENSES - 10% OFF RETAIL

ALL OTHER MATERIALS - 20% OFF RETAIL

REFRACTIVE SURGERY DISCOUNT PLAN

Superior Vision Services has contracted with Ophthalmologists who specialize in the highly publicized elective procedures of Radial Keratotomy (RK), Photo Refractive Keratotomy (PRK), and LASIK. These participating providers provide their services for the aforementioned procedures at a 20% discount off their usual and customary surgical fees (non-insured benefit) for Superior Vision Plan members. The Materials Discount also includes Blepharoplasty (upper and lower eyelid surgery).

Copyright © 2007 Pierce Group Benefits, LLC. All Right Reserved.
This website highlights the voluntary benefits offered through your employer for the current plan year. This is neither an insurance contract nor a Summary Plan Description and only the actual policy provisions will prevail. All information in this booklet including premiums quoted is subject to change. All policy descriptions are for information purposes only. Your actual policies may be different than those in this booklet. Please meet with your Colonial Representative during the Open Enrollment Period to verify the information contained within this booklet as well as your own policy information.