Vision Benefits Summary

Vision Insurance Provided by the

Guardian Life Insurance Company of America

Network

Copay
Davis Vision

Eye Exam: $10

Materials: $25
 
Exams Every Calendar Year
 
Lenses (Glasses or Contacts) Every Calendar Year

Frames  Every Two Calendar Years

 
Eye Exams
In-Network:
Covered at 100%

Out-of-Network:
Reimbursed up to $50
 
Single Vision Lenses In-Network:
Covered at 100%

Out-of-Network:
Reimbursed up to $48
 
Lined Bifocal Lenses
In-Network:
Covered at 100%

Out-of-Network:
Reimbursed up to $67
 
Lined Trifocals Lenses In-Network:
Covered at 100%

Out-of-Network:
Reimbursed up to $86
 
Lenticular Lenses In-Network:
Covered at 100%

Out-of-Network:
Reimbursed up to $126
 
Frames





In-Network:
80% of amount over $130

 Out-of-Network: Reimbursed up to $48
 
Contact Lenses  In-Network:

Elective:
85% of amount over $130 

 Medically necessary: Covered at 100%

Out-of-Network:

Elective:
Reimbursed up to $105

Medically Necessary:
Reimbursed up to $210


 *This is only a partial list of vision services. Your certificate of coverage will show exactly what is covered and excluded.