Vision Benefits

Insurance Provider:

Superior Vision Plan# 328690

Waiting Period:

1st of Month Following 30 Days

Insurance Costs & Breakdown:

Employee Only Coverage

Total Annual Cost

$72.48

Employer Annual Cost

$72.48

Employee Annual Cost

$0.00

Employee Cost Per Paycheck

$0.00

Employee + Spouse Coverage

Total Annual Cost

$123.96

Employer Annual Cost

$72.48

Employee Annual Cost

$51.48

Employee Cost Per Paycheck

$1.98

Employee + Child(ren) Coverage

Total Annual Cost

$130.80

Employer Annual Cost

$72.48

Employee Annual Cost

$58.32

Employee Cost Per Paycheck

$2.24

Employee + Family

Total Annual Cost

$196.56

Employer Annual Cost

Employee Annual Cost

$72.48

$124.08

Employee Cost Per Paycheck

$4.77

Plan Type:

Exam Co-Pay:

Materials Co-Pay:

Exam:

Frames:

Lenses per pair

Single:

Trifocal:

Progressive:

Lenticular:

Contact Lenses*:

Medically Necessary Contact Lenses:

Lasik Vision Correction:

Superior Select SW Network

$10

$25

Covered in Full 

$150 Retail Allowance 

Covered in Full

Covered in Full

Covered in Full

Covered in Full

$150 Retail Allowance

 

Covered in Full

$200 Allowance**

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements 

* Contact lenses and related professional services are covered in lieu of eyeglass lenses and frame benefit

** Lasik Vision Correction is in lieu of eye-wear benefit, subject to routine regulatory filings and certain exclusions and limitations

Platinum Control Technologies

2822 West 5th Street

Fort Worth, TX 76107

Service Office: Midland, TX

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