Vision
Visit www.surency.com/vision to find an Insight Network Provider. Surency In-Network Plan Information Base Plan (Exam Only)
Buy Up Plan
Network
Insight Network
Out-of-Network
Insight Network
Out-of-Network
Exam
$0 Copay
$40
$0 Copay
$40
Exam Frequency
Once Per Calendar Year
Once Per Calendar Year
Lens Frequency
Unlimited
Once Per Calendar Year
Frames Frequency
Unlimited
Once Every Other Calendar Year
$150 Allowance, 20% Off Balance over $150
Standard Frames
35% Off Retail
N/A
$105
Lenses (Single, Bifocal, Trifocal)
$50 | $70 | $105
N/A
$25 Copay
$30 | $50 | $70
$150 Allowance, 15% Off Balance over $150
Conventional Contact Lenses
15% Off Retail
N/A
$120
Disposable Contact Lenses
Not Covered
N/A
$150 Allowance
$120
Medically Necessary Contact Lenses
Not Covered
N/A
100% Covered
$210
Base Plan (Exam Only)
Annually
Monthly
Bi-weekly (20)
Bi-weekly (26)
Employee Only
$0
$0
$0
$0
Employee + Spouse
$0
$0
$0
$0
Employee Child(ren)
$0
$0
$0
$0
Employee Family
$0
$0
$0
$0
Buy-Up Plan
Annually
Monthly
Bi-weekly (20)
Bi-weekly (26)
Employee Only
$49.68
$4.14
$2.49
$1.91
Employee + Spouse
$94.44
$7.87
$4.73
$3.64
Employee Child(ren)
$99.48
$8.29
$4.98
$3.83
Employee Family
$146.16
$12.18
$7.31
$5.63
20 - Employee Benefits Guide
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