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Samaritan Vision Plan Benefits

This Plan pays for vision examinations and corrective lenses and frames (when prescribed by a licensed ophthalmologist or licensed optometrist) for you and your insured dependents. The Plan allows you to choose any licensed ophthalmologist, optician, or optometrist. However, for eye examinations, there is a difference in reimbursement for participating vision providers and non-participating vision providers. 

Deductibles

There is no deductible for covered vision services or supplies and the benefits are paid, up to the limits listed in your Summary of Benefits, for services at participating vision providers. Allowed charge means the charge for covered services up to the maximum plan allowance. These vision care benefits are provided on a benefit year basis.

Small group plans

Medical embedded (pediatric) vision coverage is primary to the Vision Only plan that is purchased separately. Medical deductibles do not need to be met prior to obtaining the Vision Only plan coverage, however IF there is a deductible required for the medical plan with embedded (pediatric) vision coverage, the deductible may need to be met first.

Covered Benefits

Eye Examinations: One complete routine, non-medical, eye exam (including eye refraction exam), per calendar year.

Vision Hardware and/or Accessories: The following hardware and/or accessories are covered every 1 year at a combined benefit maximum limit of $175:

  • Single Vision Lenses
  • Polycarbonate Lenses (when appropriate)
  • Bifocal Lenses
  • Trifocal Lenses
  • Contacts
  • Contact Lenses
  • Frames
  • Lenses (including PolyCarb lenses) are covered when eyeglasses are first acquired or when required by a change in prescription
  • Progressive lenses (viralux, no line bifocals) are covered, if prescribed and billed appropriately by a licensed provider and for a diagnosis not excluded in our plan
  In-Network Out-of-Network
Copay $25 $25, then 70% coinsurance

For more information on plan benefits, limitations and exclusions, view our 2018 Vision Plan Summary of Benefits.