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Plan Description
VisionRx > Vision Service Plan
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Note: This page contains a brief summary of coverage. It does not
state all provisions and limitations of the plan. The terms and provisions of
each plan, as outlined in the plan document, will determine coverage and
eligibility.
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Broker Name:
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VisionRx (Michigan)
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Policy Number:
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34512435
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Original Plan Effective Date:
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12/11/2002
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Rate Guarantee Expiration Date:
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12/11/2002
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Plan Anniversary Date:
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12/11/2202
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Billing Cut-off Day of the Month:
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1
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Retroactive Termination Limit:
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30
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Divisions:
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All Divisions
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Locations:
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California
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Employee Classes:
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Full Time
Manager
Officer
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Validation Method:
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Automatic
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General Plan Information
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Examination
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$15 copay
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Materials
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$15 copay
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Benefit Frequency
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Examination
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12 months
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Lenses
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12 months
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Frames
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24 months
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Contacts (in lieu of Lenses and Frames)
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12 months
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Waiting Period Information
Eligible employees are eligible as of the 1st of the month following the employee's hire date.
Termination of Coverage Information
When a plan participant is terminated from the company, the plan coverage ends on the last day of the month following the employee's termination date.
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(per month)
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Employee Cost
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Company Cost
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Total
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Employee
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$0
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$15.43
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$15.43
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Employee + Spouse
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$5.23
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$49.32
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$54.55
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Employee + Child(ren)
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$32.01
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$91.02
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$123.03
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Family
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$65.23
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$154.23
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$219.46
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VisionRx
Member Services
John Carpet
P.O. Box 173
Detroit, MI
80217
(303) 741-9300
Fax (303) 225-3453
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