Benefits through Superior National network
Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements
1 Materials co-pay applies to lenses and frames only, not contact lenses
2 Standard contact lens fitting applies to a current contact lens user who wears disposable, daily wear, or extended wear lenses only. Specialty contact lens fitting applies to
new contact wearers and/or a member who wear toric, gas permeable, or multi-focal lenses.
3 If premium progressive lenses are selected, members receive an allowance based on the provider’s charges for standard progressive lenses
4 Contact lenses are in lieu of eyeglass lenses and frames benefit
Discount features
Look for providers in the provider directory who accept discounts,
as some do not; please verify their services and discounts (range
from 10%-30%) prior to service as they vary.
Discounts on covered materials
Frames: 20% off amount over allowance
Lens options: 20% off retail
Progressives: 20% off amount over retail lined trifocal
lens, including lens options
Specialty contact lens fit: 10% off retail, then apply allowance
Maximum member out-of-pocket
The following options have out-of-pocket maximums5 on standard
(not premium, brand, or progressive) lenses.
Single vision Bifocal & trifocal
Scratch coat $13 $13
Ultraviolet coat $15 $15
Tints, solid or gradients $25 $25
Anti-reflective coat $50 $50
Polycarbonate $40 20% off retail
High index 1.6 $55 20% off retail
Photochromics $80 20% off retail
12
Copays Monthly premiums Services/frequency
Exam $20 Retiree only $6.99 Exam 12 months
Materials1 $15 Retiree + family $15.88 Frame 24 months
Contact lens fitting $20 Contact lens fitting 12 months
(standard & specialty) Lenses 12 months
Contact lenses 12 months
(Based on date of service)
In-network Out-of-network
Exam (ophthalmologist) Covered in full Up to $44 retail
Exam (optometrist) Covered in full Up to $39 retail
Frames $130 retail allowance Up to $64 retail
Contact lens fitting (standard2) Covered in full Not covered
Contact lens fitting (specialty2) $50 retail allowance Not covered
Lenses (standard) per pair
Single vision Covered in full Up to $34 retail
Bifocal Covered in full Up to $48 retail
Trifocal Covered in full Up to $64 retail
Progressives (standard)3 Covered in full Up to $48 retail
Lenticular Covered in full Up to $88 retail
Factory scratch coat Covered in full Not covered
Contact lenses4 $120 retail allowance Up to $100 retail
Medically necessary contact lenses Covered in full Up to $210 retail
superiorvision.com
(800) 507-3800
5 Discounts and maximums may vary by lens type. Please check with your provider.
Discounts on non-covered exam, services and materials
Exams, frames, and prescription lenses: 30% off retail
Lens options, contacts, miscellaneous options: 20% off retail
Disposable contact lenses: 10% off retail
Retinal imaging: $39 maximum out-of-pocket
Refractive surgery
Superior Vision has a nationwide network of independent
refractive surgeons and partnerships with leading LASIK
networks who offer members a discount. These discounts range
from 10%-50%, and are the best possible discounts available to
Superior Vision.
North Carolina residents: Please contact our customer service department if you
are unable to secure a timely (at least 30 days) appointment with your provider or
need assistance finding a provider within a reasonable distance (30 miles) of your
The Plan discount features are not insurance. residence. Adjustments to your benefits may be available
All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the
allowances, minus available discounts. These are not covered by the plan.
Discounts are subject to change without notice.
Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision
plan. Please check with your Human Resources department if you have any questions.
Superior Vision Services, Inc. P.O. Box 967 Rancho Cordova, CA 95741 (800) 507-3800 superiorvision.com
The Superior Vision Plan is underwritten by National Guardian Life Insurance Company. National Guardian Life Insurance Company is not affiliated with
The Guardian Life Insurance Company of America, AKA The Guardian or Guardian Life
NVIGRP 5-07 1018-BSv2/NC