Dental Insurance Vision Insurance
EMPLOYEE BENEFITS
Carrier Name Superior Vision ABOUT VISION Vision insurance provides coverage for routine eye examinations and can help with covering some of the costs for eyeglass frames, lenses or contact lenses.
For full plan details, please visit your benefit website: www.mybenefitshub.com/pinetreeisd
You may choose from two plans: High Plan Option, or Low Plan Option Copays Exam Materials
Benefit Summary
Services/frequency
High $25 $25
Low $25 $25
Exam Frame Lenses Contacts
High DPPO In-network Out-of-network
Exam
Covered in full $175 retail Frames allowance Lenses (standard) per pair Single Vision Covered in full Bifocal Covered in full Trifocal Covered in full
Up to $35
Monthly Premiums
High Low 12 months 12 months 24 months 12 months 12 months
Employee Employee + 1 Dependent Employee + Family
Low DPPO In-network Out-of-network Covered in full $175 retail allowance
Up to $35
Up to $25 Up to $40 Up to $45
Covered in full Covered in full Covered in full
Up to $25 Up to $40 Up to $45
Up to $70
Up to $70
Progressive Polycarbonate Tints
See description1 Covered in full Covered in full
Up to $45 Up to $20 Up to $15
See description1 Covered in full Not covered
Up to $45 Up to $20 Not covered
Photochromic Lenticular
Covered in full Covered in full $175 retail allowance
Up to $40 Up to $80
Not covered Covered in full $150 retail allowance
Not covered Up to $80
Covered in full
Up to $150
Contact Lenses2
Up to $80
Medically Necessary Contact Covered in full Up to $150 Lenses Lasik Vision $200 allowance3 Correction
High $10.52 $15.25 $27.33
Low $7.62 $11.04 $19.80
Discount Features Non-Covered Eyewear Discount: Members may also receive a discount of 20% from a participating provider’s usual and cus tomary fees for eyewear purchases which exceed the benefit coverage (except disposable contact lenses, for which no discount applies ). This includes eyeglass frames which exceed the selected benefit coverage, specialty lenses (i.e. progressives) and lens “ extras” such as tints and coatings. Eyewear purchased from a Walmart Vision Center does not qualify for this additional discount because of Walmart’s “Always Low Prices” policy.
Up to $80
$200 allowance3
Co-pays apply to in-network benefits; Co-pays for out-of-network visits are deducted from reimbursements 1. Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay 2. Contact lenses and related professional services (fitting, evaluation and follow-up) are covered in lieu of eyeglass lenses and frames benefit 3. Lasik Vision Correction is in lieu of eyewear benefit, subject to routine regulatory filings and certain exclusions and limitation 23
