VISION PLAN SUMMARY
The Superior Vision National Network offers the flexibility of choice to keep outof-pocket costs low — members may opt to get the exam and materials at one location or get the exam at one location and the materials at another location , with in-network or out of network providers . Some benefits are only available from in-network providers . This comparison of benefits is a basic summary only . Refer to the Human Resources portal for the plan document .
Employee Rate Information 2021
Low Plan
High Plan
Coverage Level Bi-weekly Annual Bi-weekly Annual
Employee Only $ 1.97 $ 51.24 $ 2.24 $ 58.32
Employee + 1 $ 4.09 $ 106.44 $ 4.67 $ 121.32
You have the option of choosing any provider , whether in or out of the Superior Vision network , however you will maximize your cost-savings by using an in-network provider . Call Superior Vision at 1-800-847- 3553 or visit superiorvision . com
Employee + Family $ 6.24 $ 162.36 $ 7.12 $ 185.16
Benefit Description Superior Vision Low Plan Superior Vision High Plan
In-Network Copay Out-of-Network Copay In-Network Copay Out-of-Network Copay
Exam with an Ophthalmologist ( Every 12 months ) |
$ 10 , then covered in full |
$ 10 , then up to $ 42 |
$ 10 , then covered in full |
$ 10 , then up to $ 42 |
|
Exam with an Optometrist
( Every 12 months )
|
$ 10 , then covered in full |
Up to $ 37 Retail |
$ 10 , then covered in full |
Up to $ 37 Retail |
Standard Lenses ( Every 12 months ) |
$ 10 Materials ; Single , Bifocal , Trifocal covered in full . Polycarbonate for dependents under 18 covered in full |
Single up to $ 32 Bifocal up to $ 46 Trifocal up to $ 61 Polycarbonate not covered |
$ 10 Materials ; Single , Bifocal , Trifocal covered in full . Polycarbonate for dependents under 18 covered in full |
Single up to $ 32 Bifocal up to $ 46 Trifocal up to $ 61 Polycarbonate not covered |
Standard Frames |
Every 24 Months $ 130 Retail Allowance |
Every 24 Months Up to $ 68 retail |
Every 12 Months $ 140 Retail Allowance |
Every 12 Months Up to $ 68 retail |
Contact LensFitting ( CLF ) ( Once every 12 months )
Contact Lenses ( In lieu of eyeglasses once every 12 months )
Refractive Eye Surgery for Lasik
$ 5 , then covered in full . Specialty CLF up to $ 50 allowance
Not Covered
$ 0 , then covered in full . Specialty CLF up to $ 50 allowance
Not Covered
$ 120 Retail Allowance Up to $ 100 $ 130 Retail Allowance Up to $ 100
Discount at participating providers
N / A
Discount at participating providers
N / A
City of Arlington / EMPLOYEE BENEFITS GUIDE 2021
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