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 |
| |
Additional $50 co pay Standard Progressive Lenses |
No Benefit Available |
| |
Additional $60 co pay Photochromic Lenses (like Transitions®) |
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, $150 allowance (less applicable co pay) toward any prescription eyeglass purchase |
Reimbursed up to $60 (no co pay if included with Eyeglass Lenses) |
CONTACT LENSES (in lieu of Eyeglasses) **
Conventional / Disposable |
$150 allowance (less applicable co pay) |
Reimbursed up to $80 (less applicable co pay) |
CONTACT LENSES (in lieu of Eyeglasses) **
Medically necessary *** |
$250 allowance (less applicable co pay) |
No Benefit Available |
| CONTACT LENS FITTING FEE |
$30 allowance |
No Benefit Available |
| LASER VISION CORRECTION (LASIK) |
Discount off U&C |
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 |
| SELECT DISCOUNT PLAN |
Included as part of the SP150 Plan.
In-network benefits only.
After initial funded benefits have been utilized, continuous savings provided beyond the plan coverage on additional eyewear purchases is available (may not be combined with any other discounts or promotional offers).
MAIL ORDER (replacement) Contact Lenses from For Eyes-Direct |
* 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 SP150 07/03