Vision
Healthy eyes and clear vision are an important part of your overall health and quality of life. You may enroll yourself and your eligible dependents or you may waive vision coverage. You do not have to be enrolled in medical coverage to elect vision coverage or cover the same dependents under medical and vision.
Although vision care services and supplies are covered in-network and out-of-network, your benefits are generally greater when you use in-network providers. Your costs are based on the family members you choose to cover.
Guardian Vision – Base
Plan Information
Plan Name: Guardian Vision – Base
Effective Date: 1/1/2023
Provider Network: Vision Service Plan (VSP)
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Exams
$10
Single Vision Lenses
$25
Bifocal Lenses
$25
Trifocal Lenses
$25
Frames
Up to $150 reimbursement
Contacts (in lieu of glasses)
Up to $150 reimbursement
Frequency
Exams
Once every 12 months
Lenses
Once every 12 months
Frames
Once every 24 months
Contacts
Once every 12 months
Out-of-Network
Exams
Up to $39
Single Vision Lenses
Up to $23
Bifocal Lenses
Up to $37
Trifocal Lenses
Up to $49
Frames
Up to $46
Contacts (in lieu of glasses)
Up to $100
Frequency
Exams
Once every 12 months
Lenses
Once every 12 months
Frames
Once every 24 months
Contacts
Once every 12 months
Plan Documents
Contact Information
Carrier Name
XXX-XXX-XXXX
www.xyz.com
Guardian Vision – Buy Up
Plan Information
Plan Name: Guardian Vision – Buy Up
Effective Date: 1/1/2023
Provider Network: Vision Service Plan (VSP)
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Exams
$10
Single Vision Lenses
$25
Bifocal Lenses
$25
Trifocal Lenses
$25
Frames
Up to $200 reimbursement
Contacts (in lieu of glasses)
Up to $150 reimbursement
Frequency
Exams
Once every 12 months
Lenses
Once every 12 months
Frames
Once every 24 months
Contacts
Once every 12 months
Out-of-Network
Exams
Up to $39
Single Vision Lenses
Up to $23
Bifocal Lenses
Up to $37
Trifocal Lenses
Up to $49
Frames
Up to $46
Contacts (in lieu of glasses)
Up to $100
Frequency
Exams
Once every 12 months
Lenses
Once every 12 months
Frames
Once every 24 months
Contacts
Once every 12 months
Plan Documents
Contact Information
Carrier Name
XXX-XXX-XXXX
www.xyz.com