Samaritan Select

Vision benefits

• Routine care
• Eyewear
• How to find a Preferred Vision Provider
• Limitations and exclusions

If you have opted to join the Samaritan Choice Vision Plan, your vision benefits are listed as follows:

Routine care:

• A routine eye care visit is available once every 12 months
• When receiving care through a Preferred Provider – you are responsible for a $25.00 co-pay
• When receiving care through a Non-Preferred Provider – you will be responsible for a 30% co-insurance, as well as a $25.00 co-pay

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Eyewear:

• Your lenses are covered when eyeglasses are first acquired or when you have a change in prescription. Samaritan Choice Plans will pay a maximum amount for lenses or contacts every 12 months as follows:
  • Single Vision Lenses - $80.00 per pair
  • Bifocal Lenses - $119.00 per pair
  • Trifocal Lenses - $158.00 per pair
  • Contacts Lenses - $155.00 per pair
• Every 12 months you are eligible for frames coverage for a maximum of $85.00 paid by Samaritan Choice Plans

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How to find a preferred vision provider

If you have questions about whether or not your eye care provider is Preferred or Non-Preferred or need assistance with finding a provider in your area, please call Samaritan Choice Member Services at (541) 768-5216 or toll Free 1-866-300-4100.

Before receiving eye care services you should review your benefit’s exclusions and limitations list to be sure you are not responsible for services not covered by the Plan.

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Limitations and exclusions

The following are not covered benefits under this Plan.

• Any of the following services and supplies
  • Visual field charting;
  • Orthoptics or vision training;
  • Lenticular lenses;
  • Contact lenses, except as shown in the Schedule
  • Subnormal vision aids;
  • Aniseikonic lenses;
  • Tinted lenses, except no. 1 and no. 2 pink;
  • Nonprescription lenses; or
  • More than the allowance for a standard prescription when multi-focal hard resin lenses, coated lenses or no-line bifocals (blended type) are chosen;
  • Extra charges for fashion eyewear features such as blended, coated, flintglass, oversize lenses or extra charges for special frames
• Medical or surgical treatment of the eyes;
• Services and supplies which are payable under a workers' compensation or occupational disease law;
• Any expense which results from an act of declared or undeclared war or armed aggression;
• Any expense which is in excess of the maximum plan allowance;
• Replacement of lost, stolen, or broken lenses;
• Duplication or spare eyeglasses, lenses or frames;
• Any eye examination required as a condition of employment; and
• Any expense paid in whole or in part by any other provision of the Group Health Insurance Plan provided by the Policyholder

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View the Samaritan Choice Plans Vision Plan Document.