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Superior Vision Howards Grove

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Howards Grove School District September 1 2017 Superior Vision Description of Coverage Superior Vision Plan 2 Superior Vision Plan 2 Plan 2 In Network Out of Network In Network Out of Network In Network Out of Network 0 00 Copay Up to 34 00 Retail Value 0 00 Copay Up to 34 00 Retail Value 0 00 Copay Up to 34 00 Retail Value Routine Eye Examination Covered in Full Up to 34 00 Retail Value Covered in Full Up to 34 00 Retail Value Covered in Full Up to 34 00 Retail Value Contact Lens Examination Covered in Full Not a Covered Benefit Covered in Full Not a Covered Benefit Covered in Full Not a Covered Benefit Allowable Frequency every 12 months every 12 months every 12 months every 12 months every 12 months every 12 months Up to 150 00 Retail Value Once each 24 months Up to 74 00 Retail Value Once each 24 months Up to 150 00 Retail Value Once each 24 months Up to 74 00 Retail Value Once each 24 months Up to 150 00 Retail Value Once each 24 months Up to 74 00 Retail Value Once each 24 months Single Vision Covered in Full Up to 29 00 Retail Value Covered in Full Up to 29 00 Retail Value Covered in Full Up to 29 00 Retail Value Bifocal Covered in Full Up to 43 00 Retail Value Covered in Full Up to 43 00 Retail Value Covered in Full Up to 43 00 Retail Value Trifocal Applied to Progressive Lenses Insured pays the difference between standard trifocal lens and progressive lens Covered in Full Up to 53 00 Retail Value Covered in Full Up to 53 00 Retail Value Covered in Full Up to 53 00 Retail Value Once every 12 months Once every 12 months Once every 12 months Once every 12 months Once every 12 months Once every 12 months Benefit Highlights Deductible Copay Eye Examination Materials Frame Allowable Frequency Lenses Clear Standard Glass or Plastic Allowable Frequency Contact Lenses Including related diagnostic fitting evaluation services Up to 100 00 Retail Value Up to 210 00 Retail Paid in Full Value Once each 12 months Once each 12 months 4 Years 2017 2021 24 Pay Periods 4 46 Up to 100 00 Retail Value Up to 210 00 Retail Paid in Full Value Once each 12 months Once each 12 months 4 Years 2017 2021 20 Pay Periods 5 35 Up to 100 00 Retail Value Up to 210 00 Retail Paid in Full Value Once each 12 months Once each 12 months 4 Years 2017 2021 19 Pay Periods 5 63 Employee Spouse 8 91 10 69 11 25 Employee Child ren Family 10 05 15 55 12 06 18 66 12 69 19 64 Elective in lieu of frames lens Medically Required Allowable Frequency Rate Guarantee Rates Employee Up to 150 00 Voluntary vision program can be payroll deducted with pre tax allocations Up to 150 00 Up to 150 00

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Howards Grove School District September 1 2017 Superior Vision Description of Coverage Superior Vision Plan 2 Superior Vision Plan 2 Plan 2 In Network Out of Network In Network Out of Network In Network Out of Network 0 00 Copay Up to 34 00 Retail Value 0 00 Copay Up to 34 00 Retail Value 0 00 Copay Up to 34 00 Retail Value Routine Eye Examination Covered in Full Up to 34 00 Retail Value Covered in Full Up to 34 00 Retail Value Covered in Full Up to 34 00 Retail Value Contact Lens Examination Covered in Full Not a Covered Benefit Covered in Full Not a Covered Benefit Covered in Full Not a Covered Benefit Allowable Frequency every 12 months every 12 months every 12 months every 12 months every 12 months every 12 months Up to 150 00 Retail Value Once each 24 months Up to 74 00 Retail Value Once each 24 months Up to 150 00 Retail Value Once each 24 months Up to 74 00 Retail Value Once each 24 months Up to 150 00 Retail Value Once each 24 months Up to 74 00 Retail Value Once each 24 months Single Vision Covered in Full Up to 29 00 Retail Value Covered in Full Up to 29 00 Retail Value Covered in Full Up to 29 00 Retail Value Bifocal Covered in Full Up to 43 00 Retail Value Covered in Full Up to 43 00 Retail Value Covered in Full Up to 43 00 Retail Value Trifocal Applied to Progressive Lenses Insured pays the difference between standard trifocal lens and progressive lens Covered in Full Up to 53 00 Retail Value Covered in Full Up to 53 00 Retail Value Covered in Full Up to 53 00 Retail Value Once every 12 months Once every 12 months Once every 12 months Once every 12 months Once every 12 months Once every 12 months Benefit Highlights Deductible Copay Eye Examination Materials Frame Allowable Frequency Lenses Clear Standard Glass or Plastic Allowable Frequency Contact Lenses Including related diagnostic fitting evaluation services Up to 100 00 Retail Value Up to 210 00 Retail Paid in Full Value Once each 12 months Once each 12 months 4 Years 2017 2021 24 Pay Periods 4 46 Up to 100 00 Retail Value Up to 210 00 Retail Paid in Full Value Once each 12 months Once each 12 months 4 Years 2017 2021 20 Pay Periods 5 35 Up to 100 00 Retail Value Up to 210 00 Retail Paid in Full Value Once each 12 months Once each 12 months 4 Years 2017 2021 19 Pay Periods 5 63 Employee Spouse 8 91 10 69 11 25 Employee Child ren Family 10 05 15 55 12 06 18 66 12 69 19 64 Elective in lieu of frames lens Medically Required Allowable Frequency Rate Guarantee Rates Employee Up to 150 00 Voluntary vision program can be payroll deducted with pre tax allocations Up to 150 00 Up to 150 00

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Howards Grove School District September 1 2017 Superior Vision Description of Coverage Superior Vision Plan 2 Superior Vision Plan 2 Plan 2 In Network Out of Network In Network Out of Network In Network Out of Network 0 00 Copay Up to 34 00 Retail Value 0 00 Copay Up to 34 00 Retail Value 0 00 Copay Up to 34 00 Retail Value Routine Eye Examination Covered in Full Up to 34 00 Retail Value Covered in Full Up to 34 00 Retail Value Covered in Full Up to 34 00 Retail Value Contact Lens Examination Covered in Full Not a Covered Benefit Covered in Full Not a Covered Benefit Covered in Full Not a Covered Benefit Allowable Frequency every 12 months every 12 months every 12 months every 12 months every 12 months every 12 months Up to 150 00 Retail Value Once each 24 months Up to 74 00 Retail Value Once each 24 months Up to 150 00 Retail Value Once each 24 months Up to 74 00 Retail Value Once each 24 months Up to 150 00 Retail Value Once each 24 months Up to 74 00 Retail Value Once each 24 months Single Vision Covered in Full Up to 29 00 Retail Value Covered in Full Up to 29 00 Retail Value Covered in Full Up to 29 00 Retail Value Bifocal Covered in Full Up to 43 00 Retail Value Covered in Full Up to 43 00 Retail Value Covered in Full Up to 43 00 Retail Value Trifocal Applied to Progressive Lenses Insured pays the difference between standard trifocal lens and progressive lens Covered in Full Up to 53 00 Retail Value Covered in Full Up to 53 00 Retail Value Covered in Full Up to 53 00 Retail Value Once every 12 months Once every 12 months Once every 12 months Once every 12 months Once every 12 months Once every 12 months Benefit Highlights Deductible Copay Eye Examination Materials Frame Allowable Frequency Lenses Clear Standard Glass or Plastic Allowable Frequency Contact Lenses Including related diagnostic fitting evaluation services Up to 100 00 Retail Value Up to 210 00 Retail Paid in Full Value Once each 12 months Once each 12 months 4 Years 2017 2021 24 Pay Periods 4 46 Up to 100 00 Retail Value Up to 210 00 Retail Paid in Full Value Once each 12 months Once each 12 months 4 Years 2017 2021 20 Pay Periods 5 35 Up to 100 00 Retail Value Up to 210 00 Retail Paid in Full Value Once each 12 months Once each 12 months 4 Years 2017 2021 19 Pay Periods 5 63 Employee Spouse 8 91 10 69 11 25 Employee Child ren Family 10 05 15 55 12 06 18 66 12 69 19 64 Elective in lieu of frames lens Medically Required Allowable Frequency Rate Guarantee Rates Employee Up to 150 00 Voluntary vision program can be payroll deducted with pre tax allocations Up to 150 00 Up to 150 00

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Howards Grove School District September 1 2017 Superior Vision Description of Coverage Superior Vision Plan 2 Superior Vision Plan 2 Plan 2 In Network Out of Network In Network Out of Network In Network Out of Network 0 00 Copay Up to 34 00 Retail Value 0 00 Copay Up to 34 00 Retail Value 0 00 Copay Up to 34 00 Retail Value Routine Eye Examination Covered in Full Up to 34 00 Retail Value Covered in Full Up to 34 00 Retail Value Covered in Full Up to 34 00 Retail Value Contact Lens Examination Covered in Full Not a Covered Benefit Covered in Full Not a Covered Benefit Covered in Full Not a Covered Benefit Allowable Frequency every 12 months every 12 months every 12 months every 12 months every 12 months every 12 months Up to 150 00 Retail Value Once each 24 months Up to 74 00 Retail Value Once each 24 months Up to 150 00 Retail Value Once each 24 months Up to 74 00 Retail Value Once each 24 months Up to 150 00 Retail Value Once each 24 months Up to 74 00 Retail Value Once each 24 months Single Vision Covered in Full Up to 29 00 Retail Value Covered in Full Up to 29 00 Retail Value Covered in Full Up to 29 00 Retail Value Bifocal Covered in Full Up to 43 00 Retail Value Covered in Full Up to 43 00 Retail Value Covered in Full Up to 43 00 Retail Value Trifocal Applied to Progressive Lenses Insured pays the difference between standard trifocal lens and progressive lens Covered in Full Up to 53 00 Retail Value Covered in Full Up to 53 00 Retail Value Covered in Full Up to 53 00 Retail Value Once every 12 months Once every 12 months Once every 12 months Once every 12 months Once every 12 months Once every 12 months Benefit Highlights Deductible Copay Eye Examination Materials Frame Allowable Frequency Lenses Clear Standard Glass or Plastic Allowable Frequency Contact Lenses Including related diagnostic fitting evaluation services Up to 100 00 Retail Value Up to 210 00 Retail Paid in Full Value Once each 12 months Once each 12 months 4 Years 2017 2021 24 Pay Periods 4 46 Up to 100 00 Retail Value Up to 210 00 Retail Paid in Full Value Once each 12 months Once each 12 months 4 Years 2017 2021 20 Pay Periods 5 35 Up to 100 00 Retail Value Up to 210 00 Retail Paid in Full Value Once each 12 months Once each 12 months 4 Years 2017 2021 19 Pay Periods 5 63 Employee Spouse 8 91 10 69 11 25 Employee Child ren Family 10 05 15 55 12 06 18 66 12 69 19 64 Elective in lieu of frames lens Medically Required Allowable Frequency Rate Guarantee Rates Employee Up to 150 00 Voluntary vision program can be payroll deducted with pre tax allocations Up to 150 00 Up to 150 00

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Howards Grove School District September 1 2017 Superior Vision Description of Coverage Superior Vision Plan 2 Superior Vision Plan 2 Plan 2 In Network Out of Network In Network Out of Network In Network Out of Network 0 00 Copay Up to 34 00 Retail Value 0 00 Copay Up to 34 00 Retail Value 0 00 Copay Up to 34 00 Retail Value Routine Eye Examination Covered in Full Up to 34 00 Retail Value Covered in Full Up to 34 00 Retail Value Covered in Full Up to 34 00 Retail Value Contact Lens Examination Covered in Full Not a Covered Benefit Covered in Full Not a Covered Benefit Covered in Full Not a Covered Benefit Allowable Frequency every 12 months every 12 months every 12 months every 12 months every 12 months every 12 months Up to 150 00 Retail Value Once each 24 months Up to 74 00 Retail Value Once each 24 months Up to 150 00 Retail Value Once each 24 months Up to 74 00 Retail Value Once each 24 months Up to 150 00 Retail Value Once each 24 months Up to 74 00 Retail Value Once each 24 months Single Vision Covered in Full Up to 29 00 Retail Value Covered in Full Up to 29 00 Retail Value Covered in Full Up to 29 00 Retail Value Bifocal Covered in Full Up to 43 00 Retail Value Covered in Full Up to 43 00 Retail Value Covered in Full Up to 43 00 Retail Value Trifocal Applied to Progressive Lenses Insured pays the difference between standard trifocal lens and progressive lens Covered in Full Up to 53 00 Retail Value Covered in Full Up to 53 00 Retail Value Covered in Full Up to 53 00 Retail Value Once every 12 months Once every 12 months Once every 12 months Once every 12 months Once every 12 months Once every 12 months Benefit Highlights Deductible Copay Eye Examination Materials Frame Allowable Frequency Lenses Clear Standard Glass or Plastic Allowable Frequency Contact Lenses Including related diagnostic fitting evaluation services Up to 100 00 Retail Value Up to 210 00 Retail Paid in Full Value Once each 12 months Once each 12 months 4 Years 2017 2021 24 Pay Periods 4 46 Up to 100 00 Retail Value Up to 210 00 Retail Paid in Full Value Once each 12 months Once each 12 months 4 Years 2017 2021 20 Pay Periods 5 35 Up to 100 00 Retail Value Up to 210 00 Retail Paid in Full Value Once each 12 months Once each 12 months 4 Years 2017 2021 19 Pay Periods 5 63 Employee Spouse 8 91 10 69 11 25 Employee Child ren Family 10 05 15 55 12 06 18 66 12 69 19 64 Elective in lieu of frames lens Medically Required Allowable Frequency Rate Guarantee Rates Employee Up to 150 00 Voluntary vision program can be payroll deducted with pre tax allocations Up to 150 00 Up to 150 00

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Howards Grove School District September 1 2017 Superior Vision Description of Coverage Superior Vision Plan 2 Superior Vision Plan 2 Plan 2 In Network Out of Network In Network Out of Network In Network Out of Network 0 00 Copay Up to 34 00 Retail Value 0 00 Copay Up to 34 00 Retail Value 0 00 Copay Up to 34 00 Retail Value Routine Eye Examination Covered in Full Up to 34 00 Retail Value Covered in Full Up to 34 00 Retail Value Covered in Full Up to 34 00 Retail Value Contact Lens Examination Covered in Full Not a Covered Benefit Covered in Full Not a Covered Benefit Covered in Full Not a Covered Benefit Allowable Frequency every 12 months every 12 months every 12 months every 12 months every 12 months every 12 months Up to 150 00 Retail Value Once each 24 months Up to 74 00 Retail Value Once each 24 months Up to 150 00 Retail Value Once each 24 months Up to 74 00 Retail Value Once each 24 months Up to 150 00 Retail Value Once each 24 months Up to 74 00 Retail Value Once each 24 months Single Vision Covered in Full Up to 29 00 Retail Value Covered in Full Up to 29 00 Retail Value Covered in Full Up to 29 00 Retail Value Bifocal Covered in Full Up to 43 00 Retail Value Covered in Full Up to 43 00 Retail Value Covered in Full Up to 43 00 Retail Value Trifocal Applied to Progressive Lenses Insured pays the difference between standard trifocal lens and progressive lens Covered in Full Up to 53 00 Retail Value Covered in Full Up to 53 00 Retail Value Covered in Full Up to 53 00 Retail Value Once every 12 months Once every 12 months Once every 12 months Once every 12 months Once every 12 months Once every 12 months Benefit Highlights Deductible Copay Eye Examination Materials Frame Allowable Frequency Lenses Clear Standard Glass or Plastic Allowable Frequency Contact Lenses Including related diagnostic fitting evaluation services Up to 100 00 Retail Value Up to 210 00 Retail Paid in Full Value Once each 12 months Once each 12 months 4 Years 2017 2021 24 Pay Periods 4 46 Up to 100 00 Retail Value Up to 210 00 Retail Paid in Full Value Once each 12 months Once each 12 months 4 Years 2017 2021 20 Pay Periods 5 35 Up to 100 00 Retail Value Up to 210 00 Retail Paid in Full Value Once each 12 months Once each 12 months 4 Years 2017 2021 19 Pay Periods 5 63 Employee Spouse 8 91 10 69 11 25 Employee Child ren Family 10 05 15 55 12 06 18 66 12 69 19 64 Elective in lieu of frames lens Medically Required Allowable Frequency Rate Guarantee Rates Employee Up to 150 00 Voluntary vision program can be payroll deducted with pre tax allocations Up to 150 00 Up to 150 00

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