Page 11 - 2022 Fives Landis Corp Benefit Guide

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 Use Network providers for the highest level of benefits
vision provider that you have a VSP plan. The VSP provider,
will verify your benefits and you will only pay the amount To find a participating VSP provider, visit:
not covered by the plan at the time of purchase.
www.vsp.com or call 800-877-7195.

For additional savings on contacts and eyeglasses log into
your VSP account and shop on-line at Eyeconic.
In-network coverage
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 brands; $95 at $175 retail allowance; $225 for featured brands; $95 at
Walmart/Sam’s/Costco. Walmart/Sam’s/Costco.
Frames
20% discount over the allowance 20% discount over the allowance
$10 copay applies $10 copay applies
Lenses
Single vision lenses Covered at 100% after $10 copay Covered at 100% after $10 copay
Lined Bifocal / Trifocal lenses Discount on progressive and other lenses Discount on progressive and other 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
Enhanced Offers Choice
- each covered member can Additional $75 retail Frame Allowance
choose one of 5 upgrades annually Additional $75 Contact Lens Allowance
N/A Anti-Reflective coating – covered in full
Photochromatic Lenses – covered in full
- Not available at Walmart, Sam’s or
Costco Premium Progressive Lenses – covered in full
Coverage Level 2022 Vision Rates (bi-weekly)

Employee Only $2.90 $5.32

Employee + Spouse $5.81 $10.66

Employee + Child(ren) $6.20 $11.40
Family $9.93 $18.24

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 Easy Options 8
Choice under the Enhanced Plan. See the plan summary for additional details.