Page 14 - Hussmann- OE Guide
P. 14
Annual
Enrollment
Vision Vision
The vision plan is offered through Vision Service Plan (VSP) utilizing
To find a VSP doctor, the Choice network. Just a reminder, there are no ID cards issued for
visit www.vsp.com or call the vision plan. Group numbers are available on the Beneit Directory.
1-800-877-7195
Out-of-Network
Beneit Description In-Network Reimbursement
WellVision Exam * Focuses on your eyes and $10 copay Up to $45
Every calendar year overall wellness
Frame $150 allowance for a wide $25 copay Up to $70
Every other calendar year selection of frames + 20% off
the amount over your balance
Lenses Single vision, lined bifocal, and $25 copay Single: Up to $30
Every calendar year lined trifocal lenses Lined Bifocal: Up to $50
Lined Trifocal: Up to $65
Lens Options X Standard progressive X Standard Progressive: $55 Up to $50
Every calendar year lenses X Premium Progressive:
X Premium progressive $95—$105
lenses X Custom Progressive:
X Custom progressive lenses $150—$175
X Average of 20-25% off
other lenses options
Contacts $150 allowance for contacts, Contacts Fitting and Evaluation Up to $105
Instead of glasses copay does not apply; is covered up to $60
Every calendar year Contacts lens exam (itting
and evaluation)
Discounts Available (In-Network Only): 20% off additional glasses and sunglasses, including lens options, from any VSP doctor
within 12 months of your last WellVision Exam. Average of 15% off the regular price or 5% off the promotional price for laser
vision correction at contracted facilities.
Note: Frequency is based on a Calendar Year Basis: This means you can get a new exam starting every January 1, as opposed to 12 months from the
date of your last exam.
* If you are enrolled on Hussmann’s medical plan, a Well Vision Exam is covered under preventive care services at 100%.
Contribution Rates
Monthly
Vision Plan Employee
Diabetic Eyecare Plus Program Contribution
Employee (Ee) $4.89
In-network vision services related to type 1 and 2 diabetes
are available for a $20 copay with no frequency limitations. Ee + Spouse/SSDP $9.77
Ask your VSP provider for details. Ee + Child(ren) $10.46
Family $16.71
14
Enrollment
Vision Vision
The vision plan is offered through Vision Service Plan (VSP) utilizing
To find a VSP doctor, the Choice network. Just a reminder, there are no ID cards issued for
visit www.vsp.com or call the vision plan. Group numbers are available on the Beneit Directory.
1-800-877-7195
Out-of-Network
Beneit Description In-Network Reimbursement
WellVision Exam * Focuses on your eyes and $10 copay Up to $45
Every calendar year overall wellness
Frame $150 allowance for a wide $25 copay Up to $70
Every other calendar year selection of frames + 20% off
the amount over your balance
Lenses Single vision, lined bifocal, and $25 copay Single: Up to $30
Every calendar year lined trifocal lenses Lined Bifocal: Up to $50
Lined Trifocal: Up to $65
Lens Options X Standard progressive X Standard Progressive: $55 Up to $50
Every calendar year lenses X Premium Progressive:
X Premium progressive $95—$105
lenses X Custom Progressive:
X Custom progressive lenses $150—$175
X Average of 20-25% off
other lenses options
Contacts $150 allowance for contacts, Contacts Fitting and Evaluation Up to $105
Instead of glasses copay does not apply; is covered up to $60
Every calendar year Contacts lens exam (itting
and evaluation)
Discounts Available (In-Network Only): 20% off additional glasses and sunglasses, including lens options, from any VSP doctor
within 12 months of your last WellVision Exam. Average of 15% off the regular price or 5% off the promotional price for laser
vision correction at contracted facilities.
Note: Frequency is based on a Calendar Year Basis: This means you can get a new exam starting every January 1, as opposed to 12 months from the
date of your last exam.
* If you are enrolled on Hussmann’s medical plan, a Well Vision Exam is covered under preventive care services at 100%.
Contribution Rates
Monthly
Vision Plan Employee
Diabetic Eyecare Plus Program Contribution
Employee (Ee) $4.89
In-network vision services related to type 1 and 2 diabetes
are available for a $20 copay with no frequency limitations. Ee + Spouse/SSDP $9.77
Ask your VSP provider for details. Ee + Child(ren) $10.46
Family $16.71
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