Page 21 - Apricity Benefits Guide
P. 21
2020
Apricity Benefits Overview
VISION BENEFITS
VSP Vision Plan
An optional vision beneit provided through Vision Service Plan (VSP) can be elected to cover
yourself and your eligible family members. VSP is one of the largest providers of eye care
coverage. VSP doctors provide both eye exams and eyewear, making for a convenient “one-
stop” means of obtaining eye care beneits.
You may choose to receive care from a participating VSP provider or any provider of your choice.
The table below highlights the beneits available through the VSP Vision Plan.
Vision Plan Summary
This chart summarizes what is covered under the VSP Vision Plan.
Beneit Description Participating Providers VSP Vision Plan Non-Participating Providers
Service Intervals
Exam, Lenses Once every 12 months
Frames Once every 24 months
Vision Examination $10 copay Up to maximum of $45 1
Eyeglass Lenses
Single Vision Lenses Covered in full after $25 copay 2 Up to $30 1
Bifocal Lenses Covered in full after $25 copay 2 Up to $50 1
Line Trifocal Lenses Covered in full after $25 copay 2 Up to $65 1
Progressive Lenses Covered in full after $55 copay 2 Up to $50 1
Eyeglass Frames Up to $150 after $25 copay 2 Up to a maximum of $70 1
then 20% off charges over $150
Contact Lenses (in lieu lenses and frame)
Medically Necessary Covered in full 1 Up to a maximum of $210 1
Elective Up to $150 1 Up to a maximum of $105 1
1 Subject to copay, if any.
2 A $25 materials copay applies once for the purchase of prescription glasses (lenses and frame).
Vision—Employee Contributions Per Pay Period
Coverage VSP
Employee Only $3.71
Employee + Spouse $5.98
Employee + Child $5.98
Employee + Child(ren) $9.63
Family $9.63
This summary outlines the highlights of your plan. For a complete list of both covered and not covered services, including beneits
required by your state, see your employer’s insurance certiicate or Summary Plan Description for the oficial plan documents. If there
are any differences between this summary and the plan documents, the information in the plan documents takes precedence.
Table of Contents Your Quick Guide to Savings and Group Auto and Home Insurance .33
About Your Beneits Program. . . . . . .2 Spending Accounts .............16 Group Legal Services ............33
Beneits Basics ...................3 Dental Beneits .................18 Employee Assistance Program ....34
Medical/Prescription Drugs Beneits . 6 Dental Plan Summary ............20 Medicare Part D Creditable
Comparing Medical Plan Options ..7 Vision Beneits ..................21 Coverage Notice ...............35
First Stop Health ................11 Voluntary Disability Insurance .....22 Premium Assistance Under Medicaid
Medical Plan Summary ..........12 Life and AD&D Insurance ........25 and the Children’s Health Insurance
Program (CHIP) .................42
Pharmacy Plan Summary .........13 Voluntary Accident Insurance ....29 Contact Information .............46 21
Flexible Spending Accounts ......14 Voluntary Critical Illness Insurance . 31
Apricity Benefits Overview
VISION BENEFITS
VSP Vision Plan
An optional vision beneit provided through Vision Service Plan (VSP) can be elected to cover
yourself and your eligible family members. VSP is one of the largest providers of eye care
coverage. VSP doctors provide both eye exams and eyewear, making for a convenient “one-
stop” means of obtaining eye care beneits.
You may choose to receive care from a participating VSP provider or any provider of your choice.
The table below highlights the beneits available through the VSP Vision Plan.
Vision Plan Summary
This chart summarizes what is covered under the VSP Vision Plan.
Beneit Description Participating Providers VSP Vision Plan Non-Participating Providers
Service Intervals
Exam, Lenses Once every 12 months
Frames Once every 24 months
Vision Examination $10 copay Up to maximum of $45 1
Eyeglass Lenses
Single Vision Lenses Covered in full after $25 copay 2 Up to $30 1
Bifocal Lenses Covered in full after $25 copay 2 Up to $50 1
Line Trifocal Lenses Covered in full after $25 copay 2 Up to $65 1
Progressive Lenses Covered in full after $55 copay 2 Up to $50 1
Eyeglass Frames Up to $150 after $25 copay 2 Up to a maximum of $70 1
then 20% off charges over $150
Contact Lenses (in lieu lenses and frame)
Medically Necessary Covered in full 1 Up to a maximum of $210 1
Elective Up to $150 1 Up to a maximum of $105 1
1 Subject to copay, if any.
2 A $25 materials copay applies once for the purchase of prescription glasses (lenses and frame).
Vision—Employee Contributions Per Pay Period
Coverage VSP
Employee Only $3.71
Employee + Spouse $5.98
Employee + Child $5.98
Employee + Child(ren) $9.63
Family $9.63
This summary outlines the highlights of your plan. For a complete list of both covered and not covered services, including beneits
required by your state, see your employer’s insurance certiicate or Summary Plan Description for the oficial plan documents. If there
are any differences between this summary and the plan documents, the information in the plan documents takes precedence.
Table of Contents Your Quick Guide to Savings and Group Auto and Home Insurance .33
About Your Beneits Program. . . . . . .2 Spending Accounts .............16 Group Legal Services ............33
Beneits Basics ...................3 Dental Beneits .................18 Employee Assistance Program ....34
Medical/Prescription Drugs Beneits . 6 Dental Plan Summary ............20 Medicare Part D Creditable
Comparing Medical Plan Options ..7 Vision Beneits ..................21 Coverage Notice ...............35
First Stop Health ................11 Voluntary Disability Insurance .....22 Premium Assistance Under Medicaid
Medical Plan Summary ..........12 Life and AD&D Insurance ........25 and the Children’s Health Insurance
Program (CHIP) .................42
Pharmacy Plan Summary .........13 Voluntary Accident Insurance ....29 Contact Information .............46 21
Flexible Spending Accounts ......14 Voluntary Critical Illness Insurance . 31
