Superior Vision

The Visible Difference in Managed Vision Care

Presenting the Superior Vision Plan

State of Oklahoma

Benefit Frequency Type In-Network Out-of-Network

Comprehensive Eye Exam

1 per Calendar Year

Does NOT include Contact Lens Fitting exam

Covered in Full after $10 co-pay

M.D. to $34O.D. to $26

Single Vision Lenses 1 Pair per Calendar Year

Standard, Glass, or Plastic Covered in Full after $25 co-pay

Up to $26

Bifocal Lenses 1 Pair per Calendar Year

Standard, Glass, or Plastic; Covered in Full after $25 co-pay

Up to $39

Trifocal Lenses 1 Pair per Calendar Year

Standard, Glass, or Plastic;

Covered in Full after $25 co-pay

Up to $49

Lenticular Lenses 1 Pair per Calendar Year

Standard, Glass, or Plastic;

Covered in Full after $25 co-pay

Up to $78

Frame 1 per Calendar Year

Any frame Up to $125 retail Up to $68

Contact Lenses,* Elective

*Medically Necessary

1 Benefit per Calendar Year

1 Benefit per Calendar Year

Any prescription contacts

Prescription medically necessary contacts

Up to $120, no co-pay

Covered in Full

Up to $100

Up to $210

* Contact lenses are in lieu of eyeglass lenses and frames *20% discount on refractive surgery fee - LASIK, RK, PRK (laser)

Your Vision Benefits

Superior Network• The Three O’s:

• Ophthalmologists• Optometrists• Opticians

• Can use different providers for exam and materials

• Can nominate an out-of-network provider

• National and regional chains (JCPenney Optical, Pearle Vision, Lenscrafters, Target Optical

Ophthalmologists14%

Optometrists 63%

Opticians &Optical Chains

23%

42,000+ Nationwide

Online Mail-Order Contact Lenses

• Buy contact lenses online! – Treated as an In-

network contact lenses allowance

– All major brands and types of contacts.

– www.svcontacts.com– Up to 30% discount– No claim forms required– Shipped directly to you

Customer Service and Benefits Information

Customer Service 800-507-3800

Mon – Fri: 7:00am – 8:00pm CSTSaturday: 10:00am – 3:30pm CSTSunday Closed

www.superiorvision.com

•Individualized benefit information•Individualized eligibility status•Individualized claims information•Provider listings•Assistance with issues and special requests

Unparalleled Providers.

Memorable Service.Superior Choice.

Thank You.

We Look Forward to Providing You With Superior Service.