Superior Vision Insurance

This is only a summary of the benefit plan. You may review and/or obtain a copy of the certificate of coverage by contacting your Human Resources/Employee Benefits office.

RATES/PAYROLL DEDUCTION
	Materials Plan Only		Exam and Materials Plan
	10-month	12-Month	10-month	12-Month
Employee Only	$8.14	$6.78	$11.88	$9.90
Employee and One Dependent	$15.82	$13.18	$23.07	$19.22
Employee and Family	$23.19	$19.32	$33.89	$28.24

COPAYMENT
	Materials Plan Only	Exam and Materials Plan
Exam	N/A	$10.00
Materials	$15.00	$15.00
Contact Lens Fitting Exam Fee	$25.00	$25.00

In-network co-pay: Paid to the in-network provider
Out-of-network co-pay: Will be deducted from the out-of-network allowance at the time of reimbursement.
Materials co-pay: Applies to lenses and/or frames, not contact lenses

	Materials Plan Only		Exam and Materials Plan
	In-Network	Out-of-Network	In-Network	Out-of-Network
Comprehensive Exam Ophthalmologist (MD)	Not Covered	Not Covered	Covered in Full	Up to $44
Comprehensive Exam Optometrist (OD)	Not Covered	Not Covered	Covered in Full	Up to $39
Standard Lenses:
Single Vision	Covered in Full	Up to $34	Covered in Full	Up to $34
Bifocal	Covered in Full	Up to $48	Covered in Full	Up to $48
Trifocal	Covered in Full	Up to $64	Covered in Full	Up to $64
Lenticular	Covered in Full	Up to $88	Covered in Full	Up to $88
Contact Lenses*
Medically Necessary	Covered in Full	Up to $210	Covered in Full	Up to $210
Cosmetic-Elective**	Up to $120	Up to $100	Up to $120	Up to $100
Standard Contact Lens Fitting Exam Fee***	$25 Copay	Not Covered	$25 Copay	Not Covered
Specialty Contact Lens Fitting Exam Fee***	$25 Copay	Not Covered	$25 Copay	Not Covered
Frames - Standard**	Up to $100	Up to $50	Up to $100	Up to $50

* 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.

PLAN FREQUENCY
	Materials Plan Only	Exam and Materials Plan
Comprehensive Exam	N/A	12 Months
Lenses	12 Months	12 Months
Frames	24 Months	24 Months
Contact Lenses	12 Months	12 Months