Schedule of Vision Services & Copayments
Superior Vision Plan
Descriptions of Services: In-Network Non-Network
Copayments

Services/Frequency
Comprehensive Exams
Lenses
Frames
Contact Lenses

 $10 Materials Only
 

12 Months
12 Months
12 Months
12 Months

 .
Benefits
Comprehensive
Exam/Ophthalmologist
Exam/Optometrist		 Covered In Full
Covered In Full		 Up To $42
Up To $37
Lenses (Standard) Per Pair 
Single Vision
Bifocal 
Trifocal
Lenticular
Covered In Full
Covered In Full
Covered In Full
Covered In Full
Up To $32
Up To $46
Up To $61
Up To $84
Contact Lenses (Per Pair)*
Medically Necessary
Cosmetic (Elective)**
Frames (Standard)**

*Contact Lenses are in lieu of eyeglass lenses and frames benefit.

**The insured is responsible for paying any charges in excess of this allowance.
Covered In Full
Up To $120
Up To $100
 
 
 
 

 
Up To $210
Up To $100
Up To $48
 
 
 
 

 
Materials Discount Schedule:
The Superior Vision Discount Plan is available for addtional purchases of eyewear and contact lenses from in-network
providers. There are no discounts on the insured benefit.
Frames
No restrictions apply
30% Off Retail
Lenses (Uncoated Plastic-CR39, or Glass)
Single Vision
Bifocal (FT 25-35 & Executive)
Trifocal (FT 7X25, 7X28, 8X35 & Executive)
Progressives
Zyl and Metal Mounting		 30% Off Retail
ADD-ON TO BASE LENSES
Tints, Coating, Colored Lenses
Power over 4.00D Sphere, 2.00D Cylinder, 5.00D Prism
Polycarbonate, High Index, Photochromatics
Cosmetic Finishing, Beveling, Edging & Mounting		 20% Off Retail
EVERYDAY "Frame & Lens Package Pricing" 20% Off Retail
CONTACT LENSES 20% Off Retail
DISPOSABLE CONTACT LENSES 20% Off Retail
ALL OTHER MATERIALS 20% Off Retail

REFRACTIVE SURGERY DISCOUNT PLAN
Superior Vision Services has contrcted woth Ophthalmologist 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).