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Guardian Group Number: 00654321


Guardian Customer Service
1-800-627-4200 

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Vision Benefits Summary

 Provided by the

Guardian Life Insurance Company of

America



 
Network

Copay
Davis Vision

Exam
: $10 Copay                   
Materials
: $25 Copay               

 
Exams Every 12 months                                            
Lenses (Glasses or contacts) One pair every 12 months      

Frames   One set every 24 months                           
 
Eye Exams
In-Network: Covered at 100% after copay
Out-of-Network: Covered up to $50 
 
Single Vision Lenses In-Network: Covered at 100% after copay
Out-of-Network: Covered up to $48 
 
Lined Bifocal Lenses
In-Network: Covered at 100% after copay
Out-of-Network: Covered up to $67
 
Lined Trifocal Lenses In-Network: Covered at 100% after copay
Out of Network: Covered up to $86
 
Lenticular Lenses In-Network: Covered at 100% after copay
Out-of-Network: Covered up to $126
 
Frames In-Network: 80% of amount over $150
Out-of-Network: Covered up to $48

 
Contact Lenses  See attached benefits plan for details
 * This is only a partial list of vision services. See attached Guardian Benefits Plan for complete descriptions of Full Feature and Discount Access plans offered.