Page 11 - 2017 Benefits Enrollment
P. 11
Lanter Delivery Systems, Inc.
Vision Find a Vision Provider
You have the option to participate in a voluntary vision plan through VSP. Visit www.vsp.com and click “Find a
This plan allows you and covered family members to receive eye exams, Doctor” to search for vision providers
in your area
lenses, frames, and contact lenses in many instances for the cost of a
copay when you visit a physician in the VSP network. The VSP network
consists of optometrists and ophthalmologists who are in private practice.
You are responsible for iling claims for non-network services and your
out-of-pocket costs will be higher.
VSP Choice Plan
In-Network Out-of-Network
Vision Exam $10 copay $45 allowance
Lenses $25 copay
Single-Vision Covered in full $30 allowance
Bifocal Covered in full $50 allowance
Trifocal Covered in full $65 allowance
Lenticular Covered in full $100 allowance
Frames $25 copay
$130 allowance $70 allowance
Contact Lenses
Contact Lens Exam Fitting Up to $60 copay
Instead of Lenses and Frame $130 allowance $105 allowance
Medically Necessary for Speciic Covered in full $210 allowance
Conditions
Beneit Frequency
Exam 12 months
Lenses 12 months
Frames 24 months
Premium Per Pay Period
Employee $1.30
Employee and Spouse $2.07
Employee and Child(ren) $2.12
Family $3.41
11
Vision Find a Vision Provider
You have the option to participate in a voluntary vision plan through VSP. Visit www.vsp.com and click “Find a
This plan allows you and covered family members to receive eye exams, Doctor” to search for vision providers
in your area
lenses, frames, and contact lenses in many instances for the cost of a
copay when you visit a physician in the VSP network. The VSP network
consists of optometrists and ophthalmologists who are in private practice.
You are responsible for iling claims for non-network services and your
out-of-pocket costs will be higher.
VSP Choice Plan
In-Network Out-of-Network
Vision Exam $10 copay $45 allowance
Lenses $25 copay
Single-Vision Covered in full $30 allowance
Bifocal Covered in full $50 allowance
Trifocal Covered in full $65 allowance
Lenticular Covered in full $100 allowance
Frames $25 copay
$130 allowance $70 allowance
Contact Lenses
Contact Lens Exam Fitting Up to $60 copay
Instead of Lenses and Frame $130 allowance $105 allowance
Medically Necessary for Speciic Covered in full $210 allowance
Conditions
Beneit Frequency
Exam 12 months
Lenses 12 months
Frames 24 months
Premium Per Pay Period
Employee $1.30
Employee and Spouse $2.07
Employee and Child(ren) $2.12
Family $3.41
11
