CAPABILITY OVERVIEW

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14 Tonganoxie USD #464
Vision Plan
The vision benefits will continue to be offered through Superior Vision. To identify participating providers, you may
go to or call 1-800-507-3800.
Materials Only Full Benefit
Copays
- Exams
- Lenses (Single, Bifocal, Trifocal)
- Contact Lens Fitting
Not Covered
$15
$15
$15
$15
$15
Frequency Limitations
- Exams
- Lenses
- Frames
Not Covered
Once every 12 months
Once every 24 months
Once every 12 months
Once every 12 months
Once every 24 months
Reimbursement Schedule
- Exam
- Glass Lenses
- Single
- Bifocal
- Trifocal
- Progressive
- Lenticular
- Contact Lenses
- Non-elective
- Elective
- Frames
Not Covered
Covered in full
Covered in full
Covered in full
Covered at lined trifocal level
Covered in full
Covered in full
$120 allowance
$125 allowance
Covered in full
Covered in full
Covered in full
Covered in full
Covered at lined trifocal level
Covered in full
Covered in full
$120 allowance
$125 allowance
Vision Plan Cost
Materials Only Full Benefit
Employee Only $6.47 $8.41
Employee + Spouse $12.80 $16.66
Employee + Child(ren) $12.56 $16.31
Employee + Family $19.10 $24.81
This is only a summary. Please refer to your specific book/certificate for specific details. If a conflict arises, the booklet/certificate will govern in all cases.
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