Page 11 - Future Steps
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Vision Coverage 2017 Beneits Enrollment
Voluntary Vision Benefit Summary
VSP
Network: VSP Signature
Out-of-Network
In-Network Reimbursement Level
Eye Exam $10 copay Up to $50
Lenses
Single $25 copay Up to $50
Bifocal $25 copay Up to $75
Trifocal $25 copay Up to $100
Lenticular $25 copay Up to $125
Frames
$150 allowance, $170 for featured Up to $70
frame brands; 20% off balance
over allowance
Contacts
Elective Contacts in $150 allowance and up to $60 Up to $105
Lieu of Glasses copay for fitting and evaluation
Medically Necessary Covered at 100% Up to $210
Contact Lenses
Frequency
Exam, Lenses, or 12 months
Contacts (in lieu of
glasses)
Frames 12 months
Notes: this is a synopsis of coverage only; the beneits summary contains exclusions and limitations which are
not shown here. Please refer to the beneits summary for the full scope of coverage.
The vision plan will remain with VSP for 2017. The vision plan covers routine eye
exams and also pays for all or a portion of the cost of glasses or contact lenses if
you need them. Please note the dependent eligibility on the vision plan is age 19 or
25, if a full-time student.
In the vision plan, you can receive services or materials from an in-network or an No ID Card Necessary
out-of-network vision provider. If you go to an in-network provider, you will only Using your vision beneits is
pay the amounts listed in the in-network column. If you go out-of-network, you simple. Let your vision provider
will be reimbursed up to a speciic level, depending on what service or material know your coverage is through
was provided. To locate an in-network provider visit www.vsp.com and select the VSP. Your provider will verify
Signature Network or call 800.877.7195. your eligibility using your SSN.
11
Voluntary Vision Benefit Summary
VSP
Network: VSP Signature
Out-of-Network
In-Network Reimbursement Level
Eye Exam $10 copay Up to $50
Lenses
Single $25 copay Up to $50
Bifocal $25 copay Up to $75
Trifocal $25 copay Up to $100
Lenticular $25 copay Up to $125
Frames
$150 allowance, $170 for featured Up to $70
frame brands; 20% off balance
over allowance
Contacts
Elective Contacts in $150 allowance and up to $60 Up to $105
Lieu of Glasses copay for fitting and evaluation
Medically Necessary Covered at 100% Up to $210
Contact Lenses
Frequency
Exam, Lenses, or 12 months
Contacts (in lieu of
glasses)
Frames 12 months
Notes: this is a synopsis of coverage only; the beneits summary contains exclusions and limitations which are
not shown here. Please refer to the beneits summary for the full scope of coverage.
The vision plan will remain with VSP for 2017. The vision plan covers routine eye
exams and also pays for all or a portion of the cost of glasses or contact lenses if
you need them. Please note the dependent eligibility on the vision plan is age 19 or
25, if a full-time student.
In the vision plan, you can receive services or materials from an in-network or an No ID Card Necessary
out-of-network vision provider. If you go to an in-network provider, you will only Using your vision beneits is
pay the amounts listed in the in-network column. If you go out-of-network, you simple. Let your vision provider
will be reimbursed up to a speciic level, depending on what service or material know your coverage is through
was provided. To locate an in-network provider visit www.vsp.com and select the VSP. Your provider will verify
Signature Network or call 800.877.7195. your eligibility using your SSN.
11
