VISION INSURANCE PLANS for Small Groups
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Rate Guide:   NA    
Name of Plan
Effective
In-Network Deductible
In-Network
Eye Exam
In-Network
Lenses
In-Network
Contacts Allowance
In-Network
Frame Allowance
Vision Basic 12M
2-2014
$0
$20 copay
$20 copay
$105 (additional 15% off balance over allowance)
$100 (additional 20% off balance over allowance)
Vision Basic 24M
2-2014
$0
$20 copay
$20 copay
$105 (additional 15% off balance over allowance)
$100 (additional 20% off balance over allowance)
Vision Plus 12M
2-2014
$0
$10 copay
$25 copay
$130 (additional 15% off balance over allowance)
$130 (additional 20% off balance over allowance)
Vision Plus 24M
2-2014
$0
$10 copay
$25 copay
$130 (additional 15% off balance over allowance)
$130 (additional 20% off balance over allowance)
Vision Premier 12M
2-2014
$0
$10 copay
$10 copay
$115 (additional 15% off balance over allowance)
$130 (additional 20% off balance over allowance)
Vision Premier 24M
2-2014
$0
$10 copay
$10 copay
$115 (additional 15% off balance over allowance)
$130 (additional 20% off balance over allowance)
  Eff: 4-2015
Name of Plan
Effective
In-Network Deductible
In-Network
Eye Exam
In-Network
Lenses
In-Network
Contacts Allowance
In-Network
Frame Allowance
Blue View
1-2014
$25
Once every calendar year
$0 copay, then covered in full

(1 pair)
$115 allowance, then 15% off any remaining balance
$120 allowance, then 20% off any remaining balance
1-2014
$15
Once every calendar year
$0 copay, then covered in full

(1 pair)
$115 allowance, then 15% off any remaining balance
$120 allowance, then 20% off any remaining balance
Vision Rate Guide:    1-2015         
Blue Shield
Enhanced Vision Plans
Effective
In-Network Deductible
In-Network
Eye Exam
(you pay)
In-Network
Lenses
(you pay)
In-Network
Contacts Allowance
(you pay)
In-Network
Frame Allowance
Enhanced Vision 0-0-120 (V262)
1-2015
n/a
0%
(every 12mo)
0%
(every 24mo)
0%
(every 24mo)
$120
(every 24mo)
Enhanced Vision 0-0-150 (V263)
1-2015
n/a
0%
(every 12mo)
0%
(every 24mo)
0%
(every 24mo)
$150
(every 24mo)
Enhanced Vision 15-25-120 (V264)
1-2015
n/a
0%
(every 12mo)
0%
(every 24mo)
0%
(every 24mo)
$120
(every 24mo)
Enhanced Vision 15-25-150 (V265)
1-2015
n/a
0%
(every 12mo)
0%
(every 24mo)
0%
(every 24mo)
$150
(every 24mo)
Enhanced Vision Plus 0-0-150-120 ( V266)
1-2015
n/a
0%
(every 12mo)
0%
(every 24mo)
0%
(every 24mo)
$150
(every 24mo)
Enhanced Vision Plus 15-25-150-120 (V267)
1-2015
n/a
0%
(every 12mo)
0%
(every 24mo)
0%
(every 24mo)
$150
(every 24mo)
Enhanced Vision Voluntary 15-25-120 (V268)
1-2015
n/a
0%
(every 12mo)
0%
(every 24mo)
0%
(every 24mo)
$120
(every 24mo)
Blue Shield
Preferred Vision Plans
Effective
In-Network Deductible
In-Network
Eye Exam
(you pay)
In-Network
Lenses
(you pay)
In-Network
Contacts Allowance
(you pay)
In-Network
Frame Allowance
Preferred Vision 0-0-120 (V269)
1-2015
n/a
0%
(every 12mo)
0%
(every 12mo)
0%
(every 12mo)
$120
(every 24mo)
Preferred Vision 0-0-150 (V270)
1-2015
n/a
0%
(every 12mo)
0%
(every 12mo)
0%
(every 12mo)
$150
(every 24mo)
Preferred Vision 15-25-120 (V271)
1-2015
n/a
0%
(every 12mo)
0%
(every 12mo)
0%
(every 12mo)
$120
(every 24mo)
Preferred Vision 15-25-150 (V272)
1-2015
n/a
0%
(every 12mo)
0%
(every 12mo)
0%
(every 12mo)
$150
(every 24mo)
Preferred Vision Plus 0-0-150-120 (V273)
1-2015
n/a
0%
(every 12mo)
0%
(every 12mo)
0%
(every 12mo)
$150
(every 24mo)
Preferred Vision Plus 15-25-150-120 (V274)
1-2015
n/a
0%
(every 12mo)
0%
(every 12mo)
0%
(every 12mo)
$150
(every 24mo)
Preferred Vision Voluntary 15-25-120 (V275)
1-2015
n/a
0%
(every 12mo)
0%
(every 12mo)
0%
(every 12mo)
$120
(every 24mo)
Blue Shield
Ultimate Vision Plans
Effective
In-Network Deductible
In-Network
Eye Exam
(you pay)
In-Network
Lenses
(you pay)
In-Network
Contacts Allowance
(you pay)
In-Network
Frame Allowance
Ultimate Vision 0-0-120 (V276)
1-2015
n/a
0%
(every 12mo)
0%
(every 12mo)
0%
(every 12mo)
$120
(every 12mo)
Ultimate Vision 0-0-150 (V277)
1-2015
n/a
0%
(every 12mo)
0%
(every 12mo)
0%
(every 12mo)
$150
(every 12mo)
Ultimate Vision 15-25-120 (V278)
1-2015
n/a
0%
(every 12mo)
0%
(every 12mo)
0%
(every 12mo)
$120
(every 12mo)
Ultimate Vision Plus 0-0-150-120 (V279)
1-2015
n/a
0%
(every 12mo)
0%
(every 12mo)
0%
(every 12mo)
$150
(every 12mo)
Ultimate Vision Plus 15-25-150-120 (V280)
1-2015
n/a
0%
(every 12mo)
0%
(every 12mo)
0%
(every 12mo)
$150
(every 12mo)
Ultimate Vision Voluntary 15-25-150 (V281)
1-2015
n/a
0%
(every 12mo)
0%
(every 12mo)
0%
(every 12mo)
$150
(every 12mo)
Ultimate Vision 15-25-150 (V282)
1-2015
n/a
0%
(every 12mo)
0%
(every 12mo)
0%
(every 12mo)
$150
(every 12mo)
Effective: 7-2015          
UHC Vision Plan
Effective
In-Network Deductible
In-Network
Eye Exam
In-Network
Lenses
In-Network
Contacts Allowance
In-Network
Frame Allowance
Classic Vision V1352
6-2012
$0
$30
Covered in full after applicable copay 1
Up to 4 boxes of contact lenses, the fitting/evaluation fees and up to two follow-up visits are covered-in-full
(after applicable copay 1)
$130
(after applicable copay 1)
Classic Vision V1355
6-2012
$0
$30
Covered in full after applicable copay 1
Up to 4 boxes of contact lenses, the fitting/evaluation fees and up to two follow-up visits are covered-in-full
(after applicable copay 1)
$130
(after applicable copay 1)
Preferred Vision V1351
6-2012
$0
$20
Covered in full after applicable copay 1
Up to 4 boxes of contact lenses, the fitting/evaluation fees and up to two follow-up visits are covered-in-full
(after applicable copay 1)
$130
(after applicable copay 1)
Preferred Vision V1354
6-2012
$0
$20
Covered in full after applicable copay 1
Up to 4 boxes of contact lenses, the fitting/evaluation fees and up to two follow-up visits are covered-in-full
(after applicable copay 1)

$130
(after applicable copay 1)
Elite Vision V1353
6-2012
$0
$15
Covered in full after applicable copay 1
Up to 4 boxes of contact lenses, the fitting/evaluation fees and up to two follow-up visits are covered-in-full
(after applicable copay 1)
$130
(after applicable copay 1)
Elite Vision V1358
6-2012
$0
$15
Covered in full after applicable copay 1
Up to 4 boxes of contact lenses, the fitting/evaluation fees and up to two follow-up visits are covered-in-full
(after applicable copay 1)

$130
(after applicable copay 1)
1 The material copayment will apply once if frames and lenses, or contact lenses in lieu of eyewear, are purchased at the same time at a network provider.
Rate Guide:  3-2015            
Vision Applications & Forms
VISION - Name of Plan
Effective
In-Network Deductible
In-Network
Eye Exam
In-Network
Lenses
In-Network
Contacts Allowance
In-Network
Frame Allowance
Signature Plan A $25
2015
 
$25 copay
(every 12mo)
$0 copay
(every 24mo)
included in exam copay
no copay
(every 24mo)
$150 allowance for contacts and contact lens exam. 15% off contact lens exam.
$0 copay
(every 24mo)
included in exam copay and up to $150 + 20% off the amount over your allowance
Signature Plan B $25
2015
 
$25 copay
(every 12mo)
$0 copay
(every 12 mo)
included in exam copay
$0 copay
(every 12 mo)
$150 allowance for contacts and contact lens exam. 15% off contact lens exam.
$0 copay
(every 24mo)
included in exam copay) and up to $150 + 20% off the amount over your allowance
Choice Plan A $20
2015
 
$20 copay
(every 12mo)
$0 copay
(every 24mo)
included in exam copay
no copay
(every 24mo)
$150 allowance for contacts and contact lens exam. 15% off contact lens exam.
$0 copay
(every 24mo)
included in exam copay and up to $150 + 20% off the amount over your allowance
Choice Plan A $25 / $25
2015
$25 Prescription Glasses Copay
$25 copay
(every 12mo)
$0 copay
(every 24mo)
included in Prescription Glasses copay
no copay
(every 24mo)
$150 allowance for contacts and contact lens exam. 15% off contact lens exam.
$0 copay
(every 24mo)
included in Prescription Glasses copay. Up to $150 + 20% off the amount over your allowance
Choice Plan B $25
2015
 
$25 copay
(every 12mo)
$0 copay
(every 12mo) combined with exam
$0 copay
(every 12mo)
$150 allowance for contacts and contact lens exam. 15% off contact lens exam
$0 copay
(every 24mo)
Combined with exam.
Up to $150 + 20% off the amount over your allowance
Choice Plan C $25
2015
 
$25 copay
(every 12mo)
$0 copay
(every 12mo) combined with exam
$0 copay
(every 12mo)
$150 allowance for contacts and contact lens exam. 15% off contact lens exam
$0 copay
(every 12mo)
Combined with exam. $150 + 20% off the amount over your allowance
Voluntary Choice Plan B $20 / $20
2015
$25 Prescription Glasses Copay
$20 copay
(every 12mo)
$0 copay
(every 12mo)
included in Prescription Glasses copay
$0 copay
(every 12mo)
$150 allowance for contacts and contact lens exam. 15% off contact lens exam
$0 copay
(every 24mo)
Included in Prescription Glasses copay. Up to $150 + 20% off the amount over your allowance.
Voluntary Choice Plan C $25
2015
 
$25 copay
(every 12mo)
$0 copay
(every 12mo) combined with exam
$0 copay
(every 12mo)
$150 allowance for contacts and contact lens exam
$0 copay
(every 12mo)
Combined with exam. $150 + 20% off the amount over your allowance.
Voluntary Choice Plan C $20 / $20
2015
$20 Prescription Glasses Copay
$20 copay
(every 12mo)
$0 copay
(every 12mo)
included in Prescription Glasses copay
Up to $60 copay
(every 12mo)
$200 allowance for contacts; copay does not apply
$0 copay
(every 12mo)
Included in Prescription Glasses copay. Up to $200 + 20% off the amount over your allowance.
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