Page 10 - 2022 Benefit Guide Fives Inc

Vision Coverage

The VSP vision plan includes a comprehensive eye exam and savings on eyewear and eye care.
Benefits are payable each calendar year.

No ID Cards are necessary, simply notify your network vision provider that you have a VSP plan.
Use Network providers for The VSP provider, will verify your benefits and you will only pay the amount not covered by the
the highest level of benefits. plan at the time of purchase.

To find a participating VSP For additional savings on contacts and eyeglasses log into
provider, visit www.vsp.com your VSP account and shop on-line at Eyeconic.
or call 800-877-7195.

In Network Benefits are listed below.
Benefit Standard Plan Enhanced Plan
Exam $10 copay then covered 100% $10 copay then covered 100%

Frequency
Exam 12 months 12 months
Lenses 12 months 12 months
Frames (or contacts) 24 months 12 months
Contacts (or frames) 12 months 12 months

$175 retail allowance; $225 for featured $175 retail allowance; $225 for featured
brands; $95 at Walmart/Sam’s/Costco. brands; $95 at Walmart/Sam’s/Costco.
Frames
20% discount over the allowance 20% discount over the allowance
$10 copay applies $10 copay applies

Lenses Covered at 100% after $10 copay Covered at 100% after $10 copay
Single vision lenses Discount on progressive and other lenses Discount on progressive and other lenses
Lined Bifocal / Trifocal lenses

$175 allowance; no copay $175 allowance; no copay
Elective contact lenses
Contact fitting fee – up to $60 Contact fitting fee – up to $60
Additional glasses or sunglasses – 20% off Additional glasses or sunglasses – 20% off
Extra Savings Laser vision surgery: up to 15% on regular Laser vision surgery: up to 15% on regular
or 5% on promotional pricing or 5% on promotional pricing

Enahanced offers Choice Additional $75 retail Frame Allowance
- each covered member can Additional $75 Contact Lens Allowance
choose one of 5 upgrades N/A Anti-Reflective coating – covered in full
annually Photochromatic Lenses – covered in full
- Not available at Walmart, Sam’s or Costco Premium Progressive Lenses – covered in full
Coverage Level 2022 Vision Rates –Monthly
Employee $6.28 $11.52
Employee +Spouse $12.58 $23.10
Employee+Child(ren) $13.44 $24.70
Family $21.52 $39.52

Covered Benefits for non-network providers include reimbursement up to dollar limits. Exam – up to $45; Frames (retail) – up to
$70; Lenses – single up to $30 and others up to $65; Contact Lenses – up to $105. There are no additional out of network benefits
for the additional Choice benefits under the Enhanced Plan. See the plan summary for additional details.

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