(through December 31, 2021)
- Employee - $13.78
- Employee and Family - $37.88
One Year Lock-In/Lock-Out
Your election to enroll in or waive Vision Plan coverage must remain in effect for 12 months (i.e., January 1 through December 31).
- If you enroll in the Plan, you will not be able to drop coverage for yourself or your dependents until the Annual Enrollment. Changes effective will be January 1.
- If you elect not to enroll in the Plan or do not enroll an eligible spouse/child,
you may not enroll until Annual Enrollment.
You will receive benefit booklets when your enrollment application is processed. If there is a discrepancy between this handout and your benefit booklet, the benefit booklet prevails.
This policy provides vision care limited benefits health insurance only. It does not provide basic hospital, basic medical or major medical insurance as defined by the New York State Insurance Department. Coverage is limited to those charges that are necessary for a routine vision examination. Co-pays apply.
The plan does not pay for:
- orthoptics or vision training and any associated supplemental testing
- medical or surgical treatment of the eye
- eye examination or corrective eyewear required by an employer as a condition of employment
- replacement of lenses and frames that are furnished under this plan, which are lost
or broken (except at normal intervals when services are otherwise available or a warranty
The plan limits benefits for blended lenses, oversized lenses, photochromic lenses, tinted lenses, progressive multifocal lenses, coated or laminated lenses, a frame that exceeds plan allowance, cosmetic lenses; U-V protected lenses and optional cosmetic processes.
The services, exclusions and limitations listed above do not constitute a contract and are a summary only. The Guardian plan documents are the final arbiter of coverage.
Contract #GP-1-VSN-96-VIS et al.
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