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 PPO Base
Plan Information
Plan Name: Guardian Vision PPO Base
Policy Number: 579839
Effective Date: 01/01/2025
Provider Network: Guardian (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 copay
Single Vision Lenses
$25 copay
Bifocal Lenses
$25 copay
Trifocal Lenses
$25 copay
Frames
Coverage limited to $200 then plan pays 20% off of amount over allowance
Contacts (in lieu of glasses)
Coverage limited to $200
Frequency
Exams
Once every 12 months
Lenses
Once every 12 months
Frames
Once every 12 months
Contacts (in lieu of lenses and frames)
Once every 12 months
Plan Documents
Year Carrier Document Name
Contact Information
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
In-Network
Exams
$10 copay
Single Vision Lenses
$25 copay
Bifocal Lenses
$25 copay
Trifocal Lenses
$25 copay
Frames
Coverage limited to $200 then plan pays 20% off of amount over allowance
Contacts (in lieu of glasses)
Coverage limited to $200
Frequency
Exams
Once every 12 months
Lenses
Once every 12 months
Frames
Once every 12 months
Contacts (in lieu of lenses and frames)
Once every 12 months
Plan Documents
Contact Information
Guardian Vision PPO Buy-Up
Plan Information
Plan Name: Guardian Vision PPO Buy-Up
Policy Number: 579839
Effective Date: 01/01/2025
Provider Network: Guardian (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 copay
Single Vision Lenses
$25 copay
Bifocal Lenses
$25 copay
Trifocal Lenses
$25 copay
Frames
Coverage limited to $200 then plan pays 20% off of amount over allowance
*Option for a second pair of glasses
Contacts (in lieu of glasses)
Coverage limited to $200
Frequency
Exams
Once every 12 months
Lenses
Once every 12 months
Frames
Once every 12 months
Contacts (in lieu of lenses and frames)
Once every 12 months
Plan Documents
Year Carrier Document Name
Contact Information
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
In-Network
Exams
$10 copay
Single Vision Lenses
$25 copay
Bifocal Lenses
$25 copay
Trifocal Lenses
$25 copay
Frames
Coverage limited to $200 then plan pays 20% off of amount over allowance
*Option for a second pair of glasses
Contacts (in lieu of glasses)
Coverage limited to $200
Frequency
Exams
Once every 12 months
Lenses
Once every 12 months
Frames
Once every 12 months
Contacts (in lieu of lenses and frames)
Once every 12 months