Superior Vision Copay

• Superior Vision Company
• Superior Vision Copay
• What Does Superior Vision Cover

How to Use the Plan

Welcome to the Superior Vision insurance plan. Superior Vision Insurance provides primary vision care benefits including eye examinations, prescription eye wear, and contact lenses through a broad-based provider network of both ophthalmologists and optometrists. The plan also contracts with a large number of national and regional optometric chain locations.

Your first step should be to choose an eye care provider, or ensure that your current provider is part of the Superior Vision Insurance network. Go towww.superiorvision.comand click on “Locate a Provider” for an updated list. You may also call Customer Service for this information at (800) 507-3800. You will learn about “in-network” and “out-of-network” providers – an important distinction when receiving your benefits. You will also learn more about how to use your benefits, as well as the discounts that are available to you.

Remember that a routine eye exam is important not only for correcting vision problems, but for maintaining healthy eyes and overall wellness. Superior Vision Insurance eye care providers will be looking for signs that may indicate other health issues – not just vision problems. Take the time to get to know your vision plan, and start experiencing healthy eyes and healthy living.

Monthly Rates
Retiree Only: $ 6.99
Retiree & Family: $ 15.88

Outline of Benefits

Co-payments:*
$20 Comprehensive Eye Exam
$15 Materials (not applicable to contact lenses)
$20 Contact Lens Fitting Exam

Vision therapy, 3) Non-routine vision services and tests, 4) Luxury frames, 5) Premium prescription lenses, and 6) Nonprescription eyewear. For more information or detail, call 888-357-6912. Superior Vision: Materials copay applies to lenses and/or frames. Discounts for lens add-ons will be. Superior Vision contracts with various LASIK networks. Depending on your benefit coverage, a LASIK discount or allowance may be included. LASIK surgery has been FDA-approved since 1995, and is performed to correct nearsightedness, farsightedness, and astigmatism.

*In-network co-pays are paid directly to the provider.
*Out-of-network co-pays will be deducted from the out-of-network reimbursement.

*All in-network and out-of-network allowances are at the retail value. **Contact lenses are in lieu of eyeglass lenses and frames benefit. ***The insured is responsible for paying any charges in excess of this retail allowance. Materials co-pay applies to lenses and/or frames. ****Standard contact lens fitting applies to an existing contact lens user who wears disposable, daily wear, or extended wear lenses only. The specialty contact lens fitting applies to new contact lens wearers and/or a member who wears toric, gas permeable, or multifocal lenses. For the specialty fitting, the member is responsible for any charges over $50.

Slack s1. Discount Features
Discounts vary by provider but are the best possible discounts available to our members. Visit Superior Vision Insurance’s website or call Customer Service (800)507-3800 to get provider specifics.

Frames:20% discount off the difference between your chosen retail frame and the retail frame allowance.

Lens options & upgrades:20% discount off retail rate. Some options on certain lenses are discounted to a specific amount; this list does NOT include high-end, name brand, or nonstandard options.

Fixed price standard options on standard lens types include Factory Scratch coat ($13), UV coat ($15), Anti-Reflective ($50), glass coloring ($35), and solid and gradient tints ($25). On standard single vision lenses, fixed price standard options include High Index 1.6 ($55), Polycarbonate ($40), and Photochromic ($80).

Materials Discounts on Additional Purchases (off retail prices)

Discounts are subject to change without notice. Discounts do not apply when prohibited by the manufacturer.

Items or Services Not Covered
While Superior Vision Insurance offers a variety of vision benefits, there are a few items or services that are generally not covered, or have limitations to their coverage. We do offer discounts on many of these items, as outlined in our discount plan coverage information.

The following are Items or Services Not Covered or Limited Coverage*

• Non-prescription (plano) lenses, sunglasses, or contact lenses
• Any coating applied to lenses such as anti-reflective, scratch, UV, lamination, tints (except pink tint #1 and #2), and sunglass coloring
• Any lens materials other than standard plastic or glass such as polycarbonate, hi-index, polaroid, and photochromic
• Any special lens feature or treatment such as prisms, slab off, faceted, oversize lens greater than 61mm, polished bevel, groove, drill mount,
  notch, roll and polish, and blended bifocal
• Premium progressive lenses (members receive an allowance based on the provider’s charges for standard progressive lenses.)
• Replacement of broken, lost, or damaged frames and/or lenses
• Orthoptics, vision training, and developmental vision procedures
• Experimental or non-conventional treatment or device
• Medical or surgical treatment of the eyes
• Post-cataract lenses (intra-ocular)
• Subnormal or low vision aids
• Safety eyewear
• Eye examination or corrective eyewear required by an employer as a condition of employment
• Services or materials when covered under workers’ compensation or similar third party coverage
• Services or materials rendered by a provider other than an ophthalmologist, optometrist, or optician acting within the scope of his or her license
• Any additional services or procedures outside of a routine eye exam and contact lens fitting
• Services or materials rendered after the date a member ceases to be covered by the benefits plan except when vision materials ordered before
  coverage ended are delivered AND the corresponding services are provided to the member within 31 days of the initial order

Regardless of optical necessity, benefits are not available more frequently than that which is specified in the Outline of Benefits.

* Plans vary, so refer to your own specific coverage.

Dental plan

Your dental coverage, through Delta Dental of Washington, encourages regular preventive care, helps you maintain healthy teeth and gums, and helps you pay for a broad range of other dental services when treatment is needed.

Most dentists in Washington participate in a Delta Dental network and the chart below shows what you will pay when you see a network dentist.

Your dental covers diagnostic and preventive services at 100%. For restorative services and crowns, the benefit plan increases what it pays through an incentive program. As long as you see a dentist at least once per year for a covered service, your benefit level increases each year until you reach the highest incentive level.

Delta Dental does not use ID cards. For plan details, see Benefits Summaries. Curl up.

Delta Dental contact information

Policy #s: Regular 0152-30050, Transit 0037-0001(Full-time full benefits and part-time full benefits) and 0152-30030 (Part-time partial benefits), Sheriff 0285-00000

Phone: 866-229-4102

Email:Delta Dental

Web:Delta Dental

Claims: Delta Dental of Washington, P.O. Box 75983, Seattle, WA 98175-0983

Vision plan

Your vision benefits, through Vision Service Plan (VSP), make it easy for you to get the eye care you need.

You may use any eye care provider you want, but if you see a VSP provider, your out-of-pocket expenses are generally lower and the provider automatically files your claim. Kaiser Permanente provides routine vision exams under its medical plan, but none of the other vision benefits, such as frames, lenses, and contacts.

For plan details, see Benefits Summaries.

Superior Vision Company

VSP contact information

Policy #s: Regular 12-029826-2006, Transit 12-029826-2014 (Full-time full benefits and part-time full benefits) and 12-029826-2004 (Part-time partial benefits), Sheriff 12-029826-2012

Phone: 800-877-7195, 800-428-4833 (TTY)

Superior Vision Copay

Email:VSP

Web:VSP

What Does Superior Vision Cover

Claims: VSP, P.O. Box 385018, Birmingham, AL 35238-5018