Benefits - Superior Vision Insurance

How To Contact Superior Vision and Find a Superior Provider

Superior Vision Customer Service                     1-800-507-3800

 

TDD (Hearing Impaired)                                     1-916-852-2382

 

Superior Vision Customer Service/                    PO Box 967

      Claims Administration                                   Rancho Cordova, CA  95741

 

Web Site*                                                            www.superiorvision.com

 

*Provider search, print a temporary ID card, order a new ID card.

 

Premiums

Vision Premiums.

 

What Does the Plan Cover?

 

Co-payments:*    $10.00 Exam                                 $20.00 Materials                                 $25.00 Contact Lens Fitting Exam Fee   *In-network co-payments are paid directly to the provider.  Materials co-payment applies to lenses and/or frames, not contact lenses.	Plan Services Frequency   Comprehensive Exam     Once per calendar year Lenses                                 Once per calendar year Frames                                Once every other calendar yr Contact Lenses                  Once per calendar year
Benefits	In-Network	Out-of-Network
Comprehensive Exam       Ophthalmologist (MD)       Optometrist (OD) Standard Lenses (Per Pair):       Single Vision       Lined Bifocal       Lined Trifocal       Lenticutlar Contact Lenses (Per Pair):*       Medically Necessary       Elective **       Standard Contact Lens Fitting Exam Fee ***       Specialty Contact Lens Fitting Exam Fee*** Frames – Standard***	Covered in full after co-pay Covered in full after co-pay   Covered in full after co-pay Covered in full after co-pay Covered in full after co-pay Covered in full after co-pay   Covered in Full Up to $120.00 Covered in full after co-pay Up to $50.00 Up to $125.00	Up to $42.00 Up to $36.00   Up to $28.00 Up to $42.00 Up to 56.00 Up to $78.00   Up to $210.00 Up to $100.00 Not Covered Not Covered Up to $70.00
*       Contact lenses are in lieu of eyeglass lenses and frames benefit. **     The insured is responsible for paying any charges in excess of this allowance. ***    Standard contact lens fitting fee applies to an existing contact lens user who wears disposable, daily wear, or extended wear lenses only.  The specialty contact lens fitting fee applies to new contact lens wearers and/or a member who wears toric, gas permeable, or multifocal lenses.  For the specialty fit, the member is responsible for any charges over $50.

 

For additional information, see the Superior Vision Outline of Benefits

 

How To Use the Plan

Procedure when using a Superior Vision Plan in-network provider:

1.   Identify yourself to the in-network provider as a member of the Superior Vision Plan. You can use your I.D. card for this purpose or simply give the provider your name, employer name, and your unique identification number. The provider will call the Superior Vision Customer Service Department to verify your eligibility and obtain an authorization number.  The I.D. card provided to you can be used for all covered family members.

2.   After eligibility is established and an authorization number is received by the provider, services will be rendered. There is nothing else that you need to do except pay the provider directly for any appropriate co-payments or charges above the covered benefits. The in-network provider handles all claims and paperwork.

 

Procedure when using an out-of-network provider:

1.   To receive services from an out-of-network provider, it is important that you first call the Superior Vision Customer Service Department at 1-800-507-3800 to receive your own authorization number. By doing so, you may be assured of your eligibility and reimbursement for money spent.

2.   After receiving services and paying in-full for the examination and/or materials (you do not pay a co-payment to the out-of-network provider), submit your original itemized billing or receipt received from the provider, along with your authorization number to:

 

                        Superior Vision Claims Administration

                        PO Box 967

                        Rancho Cordova, CA  95741

 

3.   You will be reimbursed according to the schedule of allowances for out-of-network services. 

 

Plan Discounts

Discounts on Additional Purchases

u Prescription eyeglass lenses                                         30% off retail prices

u Add-on charges to basic lenses                                    20% off retail prices

u Contact lenses, standard hard or soft                           20% off retail prices

u All other prescription materials                                      20% off retail prices

u Eye frames                                                                        30% off retail prices

u Everyday “frame and lens package pricing”               20% off retail prices

u Disposable contact lenses                                              10% off retail prices

 

Discount SVP8-20

u Frames                                                                               20% off the difference between the covered frame allowance and the retail price of the selected frame.

Note: Discounts do not apply when prohibited by the manufacturer.

 

Add-on charges to the covered pair of lenses       Member pays 20% off retail, up to:

u Factory Scratch Coat                                                        $13 (Single Vision & Standard Lined Multifocal Lenses)

u Ultraviolet Coat                                                                 $15 (Single Vision & Standard Lined Multifocal Lenses)

u Standard Anti-Reflective Coat*                                      $50 (Single Vision & Standard Lined Multifocal Lenses)

u High Index 1.6*                                                                 $55 (Single Vision Lenses Only)

u Polycarbonate                                                                   $40 (Single Vision Lenses Only)

u Standard Photochromic                                                  $80 (Single Vision Lenses Only)

u Glass coloring                                                                   $35 (Any Type Lenses)

u Plastic Tints solid or gradient                                         $25 (Any Type Lenses)

 

                                                                            Member pays:

u Power over 4.00D Sphere,                                             20% discount off retail prices (Any Type Lenses)

        2.00D Cylinder & 5.00D Prism

u Cosmetic Finishing, Beveling,                                       20% discount off retail prices (Any Type Lenses)

        Edging & Mounting

u Miscellaneous Options                                                    20% discount off retail prices (Any Type Lenses)

 

* Higher end or brand name lens upgrades are at an additional expense to the member. Apply maximum out of pocket expense toward upgraded lens retail cost and the member is responsible for the difference less 20%.

 

Contact Lens Benefits

Contact Lenses, Elective/Cosmetic. Elective/Cosmetic contact lenses are those that are worn solely for cosmetic or convenience reasons.  They are chosen because they are preferred over the wearing of conventional eyeglasses. Contact lenses covered by the Plan must contain a prescription for correcting a vision deficiency. All charges over and above your allowance are paid directly to the provider. See the “What Does the Plan Cover” section for your contact lens benefit allowance.

Contact Lenses, Medically Necessary. These lenses must be specifically prescribed by the eye doctor to be used for the reason or reasons described below. Reimbursement for these lenses will be considered as payment-in-full when utilizing an in-network provider.

 

u Aphakia (after cataract surgery without implant lens) - A pair of prescription single vision or multifocal eye glass lenses and an eyeframe can be provided along with contact lenses prescribed for this reason.

u When visual acuity cannot be corrected to 20/70 in the better eye except through the use of contact lenses (must be 20/60 or better).

u Anisometropia of 4.0 diopters or more, provided visual acuity improves to 20/60 or better in the weak eye.

u Keratoconus.

 

Note: The narrowing of visual fields due to high minus or high plus corrections is not considered a reason for medically necessary contact lenses.

 

Contact Lens Exam/Fitting Fee: Most providers charge a fee for the fitting of contact lenses. This fee is separate from the comprehensive eye examination and will vary depending on the provider’s fee structure policies. It will also vary due to circumstances or complexities involving the physiological condition of the eyes, the lens prescription, and the type of lenses used.

 

Plan Exclusions

1.   Professional Services and/or Materials in conjunction with:

a)   compensated or special multi-focal lenses

b)   plain (non-prescription) lenses

c)   anti-reflective, scratch, UV400, or any coating or lamination applied to lenses.

d)   subnormal vision aids

e)   tints other than solid

f)    orthoptics, vision training and developmental vision procedures

g)   polycarbonate lenses

2.   Medical or surgical treatment of the eyes

3.   Any eye examination or any corrective eyewear required by an Employer as a condition of employment

4.   Any injury or illness when covered under Workers’ Compensation or similar law

5.   Plain or prescription sunglasses, no-line bifocals, blended lenses or oversize lenses. Although no-line bifocals and blended lenses are not covered, an Insured may elect to apply the maximum allowance for standard lenses toward his or her cost of progressive lenses.

6.   Subnormal vision aids

7.   Services rendered or Materials purchased outside the U.S., unless:

a)   the Member resides in the U.S.; and

b)   the charges are incurred while on a business or pleasure trip

8.   Charges in excess of the Usual, Customary and Reasonable charge for the Professional Service or Materials

9.   Experimental or non-conventional treatment or device

10. Safety eyewear

11. Spectacle lens styles, materials, treatments of “add-ons” not shown in the Benefits Summary

12. Services or Materials rendered by a provider other than an Ophthalmologist, Optometrist or Optician acting within the scope of his or her license

13. Any additional service required outside basic vision analysis for contact lenses, except fitting fees.

14. Services rendered after the date an Insured ceases to be covered under this Certificate, except when vision Materials ordered before coverage ended are delivered and the services rendered to the Insured within 31 days from the date of such order.

15. Services rendered or Materials ordered before the date of coverage began under this Certificate

16. Regardless of Optical Necessity, benefits are not available more frequently than that which is specified in the Benefits Summary