VISION PLANS
SUMMARY OF COVERAGE
Out of Network Reimbursement
Key Features
In Network Cost
Annual Well Vision Eye Exam Once Per 12 Months
$15 copay
Up to $45 Allowance
Lenses Single Vision Lined Bifocal Lined Trifocal Once Per 12 Months
Up to $32 Allowance Up to $55 Allowance Up to $65 Allowance
$30 Copay for All
Frame Retail Once Per 24 Months
100% up to $130 Retail Allowance + 20% off the Balance
Up to $71 Allowance
Contacts ( in lieu of glasses) Elective Once Per 12 Months
$100% up to a $110 Retail Allowance
Up to $98 Allowance
Contacts ( in lieu of glasses) Therapeutic Once Per 12 Months
Up to $210 Allowance
$0
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SUPERBLOOM BENEFITS GUIDE
VISION PLAN I
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