Page 11 - BOC 2021 Benefits Booklet

VISION INSURANCE

VSP
Group Number: Use SSN#
Plan: Plan C $10/$25

Copayments In-Network Benefit

Exams: $10 copay
Materials/Frames: $130 allowance

Frequency

Exams: Every 12 months

Lenses: Every 12 months
Frame: Every 12 months

Allowances In Network

Exams: $10 copay
Lenses: $25 copay
Single vision lenses: $25 copay
Bifocals: $25 copay
Trifocals $25 copay
Frames: $130 allowance
Contact Lenses $130 allowance

Questions?

Member Services: 800-877-7195
Website: www.vsp.com

11