Superior Basic Plan Superior Plus Plan
Monthly Premiums
Employee Only $5.90 $9.00
Employee + Spouse $9.30 $14.08
Employee + Child(ren) $9.52 $15.08
Employee + Family $15.10 $21.30
Co-pays
Exam $35 $35
Materials $0 $0
Contact Lens Fitting $35 $35
Services/Frequency
Exam 1 per plan year 1 per plan year
Frames 1 per plan year 1 per plan year
Contact Lens Fitting 1 per plan year 1 per plan year
Lenses 1 per plan year 1 per plan year
Contact Lenses 1 per plan year 1 per plan year
Benefits
In-Network Out-of-Network In-Network Out-of-Network
Exam (Ophthalmologist) Covered-in-full
1
Up to $42 retail Covered-in-full
1
Up to $42 retail
Exam (Optometrist) Covered-in-full
1
Up to $37 retail Covered-in-full
1
Up to $37 retail
Frames $140 retail allowance Up to $53 retail $150 retail allowance Up to $53 retail
Contact Lens Fitting (Standard) Covered-in-full
1
Not covered Covered-in-full
1
Not covered
Contact Lens Fitting (Specialty
2
) $50 retail allowance
1
Not covered $50 retail allowance
1
Not covered
Lenses (Standard) Per Pair:
Single Vision Covered-in-full Up to $32 retail Covered-in-full Up to $32 retail
Bifocal Covered-in-full Up to $46 retail Covered-in-full Up to $46 retail
Trifocal Covered-in-full Up to $61 retail Covered-in-full Up to $61 retail
Polycarbonate, for dependent
children only (up to age 25) Not covered Not covered Covered-in-full Not covered
Scratch coat (factory) Not covered Not covered Covered-in-full Not covered
Ultraviolet coat Not covered Not covered Covered-in-full Not covered
Progressive lens See description
3
Up to $61 retail $120 retail allowance
5
Up to $61 retail
Contact Lenses
4
$125 retail allowance Up to $100 retail $150 retail allowance Up to $100 retail
1
After co-pays. Co-pays apply to in-network benefits only
2
Specialty contact lens fitting fee applies to new contact lens wearers and/or a member who wears toric, gas permeable, or multifocal lenses
3
Covered at the provider’s in-office retail price for a standard lined trifocal; member pays difference between the progressive and the trifocal minus a 20%
discount on the overage. Applicable co-pay applies
4
Contact lenses are in lieu of eyeglass lenses and frame benefit
5
Overages on standard progressive lenses will be the member’s responsibility
Vision Plan Benefits for
The University of Texas System
How to Use the Plan
Welcome to Superior Vision. Superior Vision provides primary vision care benefits including eye
examinations, prescription eyewear, and contact lenses through a provider network of ophthalmologists,
optometrists, and almost every national and regional optical retail chain location.
Your first step is to choose an eye care provider, or ensure that your current provider is part of the Superior
Vision network. Go to SuperiorVision.com and use “Locate a Provider” for an updated list. You may
also call Customer Service at 800.507.3800 for this information. Within the Q&A section of this brochure,
you will learn about “in-network” and “out-of-network” providers – it is an important distinction when
receiving your benefits. You will also learn more about how to use your benefits, as well as the discounts
that are available to you.
Remember that a routine eye exam is important not only for correcting vision problems, but for maintaining
healthy eyes and overall wellness. Superior Vision eye care providers will be looking for signs that may
indicate other vision and health issues, from macular degeneration and glaucoma to diabetes, hypertension,
and high cholesterol. Take the time to get to know your vision plan, and start experiencing healthy eyes and
healthy living.
Discounts
Members should look for providers in the online provider directory who accept discounts; please verify their
discounts prior to service as discounts may vary by location. Discounts are subject to change without notice.
Discounts do not apply if prohibited by the manufacturer.
Discounts on Covered Materials
Frames: 20% off amount over allowance
Lens options: 20% off retail
Progressives: 20% off amount over retail lined trifocal lens, including lens options
Maximum Member Out-of-Pocket
The following options have out-of-pocket maximums
6
on standard (not premium, brand, or progressive)
plastic lenses.
Single Vision Bifocal and Trifocal
Scratch coat $13 $13
Ultraviolet coat $15 $15
Tints, solid or gradients $25 $25
Anti-reflective coat $50 $50
Polycarbonate $40 20% off retail
High index 1.6 $55 20% off retail
Photochromic $80 20% off retail
6
Discounts and maximums may vary by lens type. Please check with your provider. The Plan discount features are not insurance.
Discounts on Non-Covered Exam and Materials
Exams, frames, and prescription lenses: 30% off retail
Lens options, contacts, other prescription materials: 20% off retail
Disposable contact lenses: 10% off retail
Refractive Surgery
Superior Vision has a nationwide network of refractive surgeons and leading LASIK networks, including
University Lasik Specialists of Texas, who provide a discount to members. These discounts range from 15%-
50%, and are the best possible discounts available to Superior Vision. Please see our website for information
and links to the providers.
Questions and Answers
Forms & ID Cards
Where do I get my ID card?
One ID card is sent to the subscriber after enrollment for the
subscriber and all dependents covered by the plan. Additional ID
cards can be downloaded and printed directly from the member
section of our website, SuperiorVision.com, or you may call
Customer Service at 800.507.3800 to have one sent to you.
Must I show my Superior Vision ID card to the in-network
provider to receive services?
No, though the ID card includes helpful information and phone
numbers for the provider to reference regarding your benefits.
While you don’t need your card, it is important that you always
identify yourself as a Superior Vision member.
Do I need to obtain an authorization number, form, or
voucher from Superior Vision prior to obtaining services
from an in-network provider?
No, our in-network providers will handle the authorization and
claims filing processes for you.
Using Your Benefits
What is the dierence between an in-network provider and
out-of network provider?
Your vision benefits are offered through a PPO (Preferred Provider
Organization) plan. There are “in-network” providers and “out-of-
network” providers. You may obtain products or services through
any provider you choose, though you will generally pay less with our
in-network providers. When visiting an in-network provider, you are
responsible for paying any applicable co-pay, and for items that are
not covered or exceed your benefit limitations. When visiting out-of-
network providers, you pay for all services in full, and then file a
claim with Superior Vision for reimbursement according to your out-
of-network benefits schedule.
If you have questions about the amount you are being asked to pay,
request that the in-network provider call Superior Vision’s Customer
Service department.
Do my dependents need to use my personal identification
number to receive the insured benefits?
You and your covered dependents share the same personal
subscriber identification number.
May I go to one provider for the eye exam and another
provider for the materials?
Yes. Superior Vision offers choice and flexibility, enabling members
to choose the provider who best matches your location and budget
preferences. Each provider will call Superior Vision’s Customer
Service department to verify your eligibility.
How does the retail frame allowance work?
Your frame allowance (found on your card and in your Benefit
Summary) is the amount your benefits cover for your frames. If the
retail price of the frame is greater than your frame allowance, you
will pay the difference. Some providers may also give a discount on
your out-of-pocket cost for the frame.
How much will I pay if I select materials and services that are
NOT covered?
You will be responsible for the full amount for materials and services
not covered by your benefit. This may include allowance overages,
certain lens options, or materials after you have exhausted your
benefits. Based on the provider selected, discounts may apply. (See
the Discounts section.)
How can I use my cosmetic (elective) contact lens allowance?
If you choose to wear contact lenses in lieu of glasses as your vision
correction, the specified allowance may be applied toward the
purchase of any type of elective contact lenses. Your benefit is
greater when dispensed by an in-network provider.
What are “medically necessary” contact lenses?
Medically necessary (non-elective) contact lenses are prescribed by
a doctor solely for purposes of correcting a specific medical
condition, such as keratoconus or other conditions that prevent your
vision from being corrected to a specified level of visual acuity using
conventional eyeglasses. Choosing contacts over glasses for a
standard prescription is considered cosmetic/elective.
What is a Contact Lens Fitting exam?
A Contact Lens Fitting (CLF) exam measures and examines your
eyes for the purpose of evaluating them for contacts, and your
provider charges a separate fee for this service. The CLF is an
additional, stand-alone benefit – it is separate from your contact
lens benefit. Of value to you is that the CLF charges do not get
deducted from your contact lens allowance.
How are progressive lenses covered?
In the Basic Plan, progressives are covered at the provider’s in-office
retail price for a standard lined trifocal. You pay the difference
between your selected progressive lens and your provider’s lined
trifocal, less discounts when applicable. For the Plus Plan,
progressives are covered up to the retail allowance. You are
responsible for any overage, less discounts when applicable.
May I utilize in-store specials, promotions, or coupons along
with my Superior Vision Plan benefit?
Your benefits provide discounted rates from in-network providers,
and cannot be used in conjunction with coupons, promotions, sales,
or other types of discounts. An exception: if you use the services of
an in-network provider but choose to take advantage of a sale,
coupon, or other in-store special, the provider may require that you
pay in full and then submit your receipt to Superior Vision for
reimbursement at the out-of-network rates. If you have questions
about the use of discounts, call Customer Service before you seek
services as rules may vary from state to state and be subject to
state laws.
In-Network Providers
How do I know which services are oered by an in-network
Superior Vision provider?
All in-network providers are listed in our online directory with the
specific services for which they have contracted. If you need
assistance locating a provider, visit SuperiorVision.com or call
Customer Service at 800.507.3800.
What do I need to pay my in-network provider?
You pay your provider any applicable co-pay, plus you are also
responsible for paying for any services or materials that are not
covered or exceed your benefit plan coverage.
What if my eye doctor is not listed as an in-network provider?
If you have verified on our website that your provider is not a
participating provider, you may complete a Provider Nomination
form located in the member section of our website. Fill out this form
online, and check back with Superior Vision periodically to see if the
provider has joined our network.
Out-of-Network Providers
May I go to an out-of-network provider?
Yes. You and your dependents may choose services from an out-of-
network provider. You will be reimbursed at the out-of-network rate
detailed in your Benefit Summary.
How will my Superior Vision eye doctor share information
about my eye exam with my medical health plan provider?
Your doctor may complete the Provider Communication form
(available in the member section of our website) and give it to you at
the conclusion of your visit. You may take this form to your health
plan provider for review and inclusion in your chart or records. This
is NOT a referral form but a voluntary sharing of information. All
medical referrals should conform to the information detailed in your
medical health plan.
Items or Services NOT Covered
While Superior Vision offers a variety of vision benefits, there are a
few materials, services, and treatments that are generally not
covered, or have limitations to their coverage. We do offer
discounts on many of these items, as outlined in our discounts
description. Your specific Superior Vision Plan may differ, so confirm
the details of your employer’s plan prior to seeking services.
Items or Services Not Covered or Have Limited Coverage*
Non-prescription (plano) lenses of any kind, sunglasses, or
contact lenses
Any coating applied to lenses such as anti-reflective, scratch,
UV, lamination, tints (except pink tint #1 and #2), and sunglass
coloring
Any lens materials other than standard plastic or glass such as
polycarbonate, hi-index, polaroid, and photochromic
Any special lens feature or treatment such as prisms, slab off,
faceted, oversize lens greater than 61mm, polished bevel,
groove, drill mount, notch, roll and polish, and blended bifocal
Replacement of broken, lost, or damaged frames and/or lenses
Orthoptics, vision training, and developmental vision
procedures
Experimental or non-conventional treatment or device
Medical or surgical treatment of the eyes
Post-cataract lenses (intra-ocular) subnormal or low vision aids
Eye examination or corrective eyewear required by an employer
as a condition of employment
Services or materials when covered under workers’
compensation or similar third party coverage
Services or materials rendered by a provider other than an
ophthalmologist, optometrist, or optician acting within the
scope of his or her license
Any additional services or procedures outside of a routine eye
exam and contact lens fitting
Services or materials rendered after the date a member ceases
to be covered by the benefits plan except when vision materials
ordered before coverage ended are delivered AND the
corresponding services are provided to the member within 31
days of the initial order
Regardless of optical necessity, benefits are not available more
frequently than that which is specified in the Outline of Benefits.
* The Basic and Plus Plans vary, so please refer to your benefits
coverage sheet.
How can I use my benefit when seeking services from an out-
of-network provider?
First, verify that the provider you wish to see is not in our network.
Then, obtain an authorization number from our Customer Service
department. Schedule your appointment, and pay the provider
directly for the services rendered.
How do I get reimbursed when I use an out-of-network
provider?
Obtain a claim form either from the member section of our website,
or from a Customer Service Representative. Complete the claim
form and attach your original receipt or itemized bill that explains
what services were provided. Mail or fax these to Superior Vision’s
Customer Service. You will be reimbursed up to the allowable
amount as outlined in the out-of-network section of your Outline
of Benefits.
Using Discounts
What discounts are available?
Your specific discount features are listed in the Discounts section of
this brochure. You are eligible for discounts off the retail charges for
a variety of lens upgrades and add-ons, overages on frame
allowances, and/or additional frame and lens purchases. Services
must be obtained from a provider indicated in our provider
directory as accepting our discounts as some providers do not. Be
sure to show your Superior Vision ID card to ensure you receive
these discounts.
Are there any limitations on the frame selection when using
the discounts?
Unless otherwise prohibited by the manufacturer, the frame
discount may be applied to any frame as long as you seek services
from a provider who accepts our discounts.
Can discounts be applied toward the purchase of prescription
sunglasses, i.e., tints to a covered lens?
Unless otherwise prohibited by the manufacturer, the discounts for
lens tinting can be applied as long as you seek services from a
provider who accepts our discounts.
Superior Vision’s SmartAlert Vision Wellness Program
What is Superior Vision’s SmartAlert program?
Superior Vision’s SmartAlert program facilitates communication
between you, your eye care provider, and your medical plan
providers about lifestyle or health issues that may impact your eyes
and vision. While participation is completely voluntary by both
members and providers, participation may help you keep on top of
current health issues or aid in the early recognition and diagnosis of
something new. The SmartAlert program includes the My Vision
Lifestyle Update and Provider Communications forms.
How may I obtain a copy of the My Vision Lifestyle form?
This form is available within the member section of our website.
You may print it, complete it, and take it with you to your eye
care appointment.
Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance
Coverage for your vision plan.
The Superior Vision Plan is underwritten 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.
NVIGRP 5-07 SVS-FUL14-208v2 04/2015
