Page 21 - Franklin Madison 2021 Benefits Guide
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Vision Plan
The Vision Service Choice Plan (VSP) is a full-service plan that offers choice, flexibility,
and maximum value through a VSP Network Provider.
Employee Cost of Vision Option Coverage Levels
Biweekly Paycheck Contributions Coverage levels are available for:
Full-Time Part-Time y Employee Only y Employee + Spouse
y Employee + y Employee + Family
Employee $3.68 $3.68 Child(ren)
Employee + Child(ren) $8.03 $8.03
Decline Coverage
Employee + Spouse $7.50 $7.50 If you decline dental coverage when you irst
become eligible, you will have to wait until the
Employee + Family $10.81 $10.81
next annual enrollment to elect it, unless you have
a qualiied life status change during the year, as
To locate a VSP Provider... explained on page 6.
The VSP has a network of over 24,000 participating For more detailed coverage information, access the
doctors nationwide, including ophthalmologists and online Beneits Portal, www.paylocity.com
optometrists.
Visit www.vsp.com or call 800.877.7195 to ind a
provider near you.
Beneit In-Network Provider Out-of-Network Provider
Annual Eye Exam $10 copay Up to $45 reimbursement after $10 copay
Lenses*
Single $20 copay Up to $30 reimbursement after $20 copay
Bifocal $20 copay Up to $50 reimbursement after $20 copay
Trifocal $20 copay Up to $65 reimbursement after $20 copay
Frames*
Every two (2) years Up to $130 reimbursement after $20 Up to $47 reimbursement after $20 copay
copay**
Contacts
Necessary $20 copay Up to $120 allowance after $20 copay
Cosmetic Up to $120 allowance Up to $105 allowance after $20 copay
* Lenses and frames purchased together are subject to one copay.
** If you select a frame over the plan’s frame allowance, you are responsible for the additional cost. You should ask your provider what your cost for
the frames will be prior to purchasing them. You can also receive a 20% discount toward the purchase of anything over the allowance on frames
and lens options as well as additional complete pairs of prescription glasses (lenses, lens options and frames).
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The Vision Service Choice Plan (VSP) is a full-service plan that offers choice, flexibility,
and maximum value through a VSP Network Provider.
Employee Cost of Vision Option Coverage Levels
Biweekly Paycheck Contributions Coverage levels are available for:
Full-Time Part-Time y Employee Only y Employee + Spouse
y Employee + y Employee + Family
Employee $3.68 $3.68 Child(ren)
Employee + Child(ren) $8.03 $8.03
Decline Coverage
Employee + Spouse $7.50 $7.50 If you decline dental coverage when you irst
become eligible, you will have to wait until the
Employee + Family $10.81 $10.81
next annual enrollment to elect it, unless you have
a qualiied life status change during the year, as
To locate a VSP Provider... explained on page 6.
The VSP has a network of over 24,000 participating For more detailed coverage information, access the
doctors nationwide, including ophthalmologists and online Beneits Portal, www.paylocity.com
optometrists.
Visit www.vsp.com or call 800.877.7195 to ind a
provider near you.
Beneit In-Network Provider Out-of-Network Provider
Annual Eye Exam $10 copay Up to $45 reimbursement after $10 copay
Lenses*
Single $20 copay Up to $30 reimbursement after $20 copay
Bifocal $20 copay Up to $50 reimbursement after $20 copay
Trifocal $20 copay Up to $65 reimbursement after $20 copay
Frames*
Every two (2) years Up to $130 reimbursement after $20 Up to $47 reimbursement after $20 copay
copay**
Contacts
Necessary $20 copay Up to $120 allowance after $20 copay
Cosmetic Up to $120 allowance Up to $105 allowance after $20 copay
* Lenses and frames purchased together are subject to one copay.
** If you select a frame over the plan’s frame allowance, you are responsible for the additional cost. You should ask your provider what your cost for
the frames will be prior to purchasing them. You can also receive a 20% discount toward the purchase of anything over the allowance on frames
and lens options as well as additional complete pairs of prescription glasses (lenses, lens options and frames).
21
