City Care Benefits Vision Plan Summary

2006 Renewal

 

 

SAFEGUARD PPO VISION PLAN (HIGH OPTION):

Participating and Non-Participating Provider Benefits

 

 

$10 Exam Deductible per Covered Member (1 exam every 12 months)

·        100% Benefit – Participating Provider

·        $45 Maximum Benefit – Non-Participating Provider

Frames (one frame every 24 months)

·        $85 Maximum Benefit – Participating Provider

·        $45 Maximum Benefit – Non-Participating Provider

Standard Corrective Lenses (one pair every 12 months)

·        100% - Participating Provider

·        Maximum Allowance Schedule – Non-Participating Provider

Medically Necessary Contact Lenses (one pair single lenses every 12 months)

Up to $250 ($125 per lens) Maximum Benefit

Cosmetic Contact Lenses (1 pair every 12 months in lieu of other vision materials)

Up to $120 Maximum Benefit – Participating Provider

Up to $105 Maximum Benefit – Non-Participating Provider

 

Monthly Premiums:   Employee Only                    $ 9.72

                                      Employee & Spouse           17.39

                                      Employee & Child(ren)      16.50

                                      Employee & Family             24.17

 

 

SAFEGUARD HMO VISION PLAN (LOW OPTION):

All Covered Services Must be Provided by a Participating Provider

 

$10 Exam Deductible per Covered Member (1 exam every 12 months)

$25 Frame and Lenses Deductible per Covered Member (a frame and a pair of lenses every 24 months)

Up to $35 Maximum Benefit for Frames

Standard Corrective Lenses @ 100%

Up to $250 Maximum Benefit for Medically Necessary Contact Lenses (one pair single lenses every 24 months; $125 per lens maximum benefit)

Up to $100 Maximum Benefit for a pair of Cosmetic Contact Lenses

 

Monthly Premiums:   Employee Only                    $  6.04

                                      Employee & Spouse             10.86

                                      Employee & Child(ren)        10.26

                                      Employee & Family               15.08

 

NOTE:

1.    Vision Plan Rates are Guaranteed to August 1, 2006.

2.    Vision Plans Will Cover 2+ Eligible Employee Groups.

 

 

NOTE:  The City Care Benefits plan descriptions provide a brief summary of the benefits only and are not complete regarding all the provisions of the plans, including limitations and exclusions

 

 

 

 

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