19th February'2003
@ascambel
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| Descriptions of Services: | In-Network | Non-Network |
| Copayments
Services/Frequency
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$10 Materials Only
12 Months
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. |
| 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
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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).
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).