Coverage
|
In-Network Benefits
|
Out-of-Network Reimbursement Benefits*
|
| COMPREHENSIVE EYE EXAMINATION |
Co-pay (refer to ID Card) |
Reimbursed up to $40 (less applicable co-pay) |
| EYEGLASS LENSES (standard plastic) |
Co-pay (refer to ID Card) includes:
Single
Bifocal
Trifocal
Lenticular |
Reimbursed
(less applicable co-pay):
Single - up to $20
Bifocal - up to $40
Trifocal - up to $60
Lenticular - up to $100 |
| |
Polycarbonate lenses covered-in-full for members age 19 and younger; $30 co-pay over the age of 19. |
No Benefit Available |
| |
Additional $50 co-pay Standard Progressive Lenses |
No Benefit Available |
| |
Additional $60 co-pay Transitions® (Photochromic) Lenses |
No Benefit Available |
| EYEGLASS FRAMES |
Co-pay (refer to ID Card) (no co-pay if included with Eyeglass Lenses); paid in full on Special Frame Selection; outside of the Selection, $100 allowance (less applicable co-pay) toward any prescription eyeglass purchase |
Reimbursed up to $40 (less applicable co-pay) |
CONTACT LENSES (in lieu of Eyeglasses) **
Conventional / Disposable |
$100 allowance (less applicable co-pay) |
Reimbursed up to $60 (less applicable co-pay) |
CONTACT LENSES (in lieu of Eyeglasses) **
Medically necessary *** |
$250 allowance (less applicable co-pay) |
$250 allowance (less applicable co-pay) |
| CONTACT LENS FITTING FEE |
$30 allowance |
No Benefit Available |
| LASER VISION CORRECTION (LASIK) |
Discount Pricing
|
No Benefit Available |
Benefit Frequency
| EXAMINATION |
Once every 12 or 24 months |
| EYEGLASS LENSES (standard plastic) |
Once every 12 or 24 months |
| EYEGLASS FRAMES |
Once every 12 or 24 months |
| CONTACT LENSES (in lieu of Eyeglasses) |
Once every 12 or 24 months |
Printable version of the Select Plus 100 Plan can be downloaded here.
* Submit Member Out-Of-Network Reimbursement Form and copy of paid receipt to Advantica EyeCare.
** This benefit is paid only once during the Group's Benefit Period and must be fully utilized at the time of purchase.
*** Limited to Aphakia, Keratoconus or Severe Anisometropia and requires pre-authorization by Advantica.
Plan is qualified under IRS Section 125.
Insurance coverage provided by National Guardian Life Insurance Company. National Guardian Life Insurance Company is not affiliated with the Guardian Life Insurance Company of America a/k/a The Guardian or Guardian Life. (Policy Form Series NVIGRP 5/07 and/or NVIGRP2002)
AEC.SB PDM SP100 07/03