Page 13 - 2022-23 Drug Plastics Benefit Guide

VSP Vision Plan

The vision plan provides coverage for routine eye exams and pays for all or a portion of the cost of glasses or contact
lenses. You can choose any provider; however, you always save money if you see in-network providers. We offer a vision
plan through VSP. VSP provides a robust provider network. Contact VSP at vsp.com or 800-877-7195 to learn more about
VSP and your benefit program.

Many In-Network services are covered at 100% following a $10 copay, up to a maximum allowed based on contracted rates
with the participating provider. Program allowances represent the amount of reimbursement to the employee for using
both the In-Network and Out-of-Network providers. If you see an Out-of-Network provider, you can submit a claim form for
some reimbursement toward your expenses.

VSP Vision Plan

Plan Provisions In-Network Out-of-Network
Exam $10 copay Up to $45
Frames (up to a maximum allowance;
coverage charged at 30%) $130 allowance Up to $70
Lenses
΅ Single vision lenses $10 copay Up to $30
΅ Bifocal lenses $10 copay Up to $50
΅ Trifocal lenses $10 copay Up to $65
Contact Lenses
΅ Contacts $130 allowance Up to $105
΅ Fitting and Evaluation $60 copay Up to $45

Frequency
΅ Exam Once every plan year Once every plan year
΅ Lenses Once every plan year Once every plan year
΅ Frames Once every plan year Once every plan year
΅ Contact lenses Once every plan year Once every plan year

Notes:
΅ Payment will be made for either frames/lenses or contact lenses within a benefit period. Payment will not be made for both.
΅ This is a general description of benefits, limitations and exclusions of the vision plan coverage; the terms and condition
of coverage shall be governed solely by the contract issued to the group. Contact your employer or marketing
representative for additional benefit details.
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