Page 33 - 2022 Insurity OE Guide FINAL

VSP – Vision Plan Summary

Group #30030303 – Choice Network

Your Coverage with a VSP Provider
COPAY FREQUENCY
WellVision® Exam • Focuses on your eyes and overall wellness $10 Every calendar year
See frames and
Prescription Glasses $10
lenses
• $170 featured frame brands allowance
Included in Every other
Frame • $150 frame allowance
prescription glasses calendar year
• 20% savings on the amount over your allowance
• Single vision, lined bifocal, and lined
Included in
Every
Lenses trifocal lenses prescription glasses calendar year
• Impact-resistant lenses for dependent children
• Standard progressive lenses
• Premium progressive lenses $0
Every
Lens Enhancements • Custom progressive lenses $95 – $105 calendar year
• Average savings of 30% on other lens $150 – $175
enhancements
• $150 allowance for contacts; copay does not apply Every
Contacts (Instead of Glasses)* Up to $60
• Contact lens exam (fitting and evaluation) calendar year
• Retinal screening for members with diabetes
• Additional exams and services for members
with diabetes, glaucoma, or age-related macular
degeneration
Primary Eyecare SM • Treatment and diagnosis of eye conditions, $0 As needed
including pink eye, vision loss, and cataracts $20 per exam
available for all members
• Limitations and coordination with your medical
coverage may apply. Ask your VSP doctor
for details
Extra Savings
• Extra $20 to spend on featured frame brands. Go to www.vsp.com/offers for details
Glasses and Sunglasses • 20% savings on additional glasses and sunglasses, including lens enhancements, from any
VSP provider within 12 months of your last WellVision Exam
Routine Retinal Screening • No more than $39 copay on routine retinal screening as an enhancement to a WellVision Exam
• Average 15% off the regular price or 5% off the promotional price; discounts only available from
Laser Vision Correction
contracted facilities
* A benefit for lenses and contact lenses is not available in the same plan year. A benefit would be paid for either one or the other. However, a member
can have a $150 benefit allowance for contact lenses plus receive a 20% discount off a complete pair of glasses.

Your Coverage With Out-of-Network Providers

Get the most out of your benefits and greater savings with a VSP network doctor. Call Member Services for
out-of-network plan details.
Coverage with a retail chain may be different or not apply. Log in to vsp.com to check your benefits for eligibility and to confirm in-network locations
based on your plan type. VSP guarantees coverage from VSP network providers only. Coverage information is subject to change. In the event of a conflict
between this information and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by
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location. In the state of Washington, VSP Vision Care, Inc., is the legal name of the corporation through which VSP does business.