Coverage
|
In-Network Benefits
|
Out-of-Network Reimbursement Benefits*+
|
| COMPREHENSIVE EYE EXAMINATION |
Applicable Copayment |
Reimbursed up to $40
(less applicable copayment) |
| EYEGLASS LENSES (standard plastic) |
Applicable Copayment:
Single
Bifocal
Trifocal
Lenticular |
Reimbursed
(less applicable copayment):
Single - up to $20
Bifocal - up to $40
Trifocal - up to $60
Lenticular - up to $100 |
| |
Polycarbonate lenses covered-in-full for members age 19 or younger; $30 copayment over the age of 19. |
No Benefit Available |
| |
Additional $50 copayment Standard Progressive Lenses |
No Benefits Available |
| |
Additional $60 copayment Photochromic Lenses (like Transitions®) |
No Benefit Available |
| EYEGLASS FRAMES |
Applicable Copayment includes $150 eyeglass frame allowance towards any frame. Copayment waived if included with eyeglass lenses.
|
Reimbursed up to $60 (no copayment if included with eyeglass lenses) |
CONTACT LENSES (in lieu of Eyeglasses) **
Conventional / Disposable |
$150 allowance (less applicable copayment) |
Reimbursed up to $80 (less applicable copayment) |
CONTACT LENSES (in lieu of Eyeglasses) **
Medically necessary *** |
$250 allowance (less applicable copayment) |
No Benefit Available |
| CONTACT LENS FITTING FEE |
$40 allowance |
No Benefit Available |
| LASER VISION CORRECTION (LASIK) |
Discounted pricing
|
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.
** 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.
Advantica is a Florida prepaid limited health service organization licensed under chapter 636.
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)
+Advantica's Florida PLHSO contracts: no out-of-network benefits.
++Advantica's Florida PLHSO contracts: 12-12-12 benefit frequency only.
AEC.SB PDM SP150 07/03