Page 11 - 2021 Sample Benefit Booklet
P. 11
VISION COVERAGE
VSP
ABC Group offers two vision plan options through VSP. ABC Group will contribute 100% of the employee
only cost toward the Materials Only plan. Employee’s are responsible for paying the cost of their
dependents.
VSP Plan A (MaterialsOnly)
Copay VSP Choice Providers Non‐VSP Providers
Exam Not Covered Not Covered
Materials (Lenses, Frames &Contacts) $10 Copay Reimbursement ScheduleVaries
Benefit/Allowance VSP Choice Providers Non‐VSP Providers
Lenses
• SingleVision 100% Up to $30
• LinedBifocal 100% Up to $50
• Lined Trifocal 100% Up to$65
Frame Allowance Up to $150 $70 Retail
Contacts VSP Choice Providers Non‐VSP Providers
MedicallyNecessary 100% Covered Up to$105
Elective Up to $150 Up to$105
Frequency VSP Choice Providers Non‐VSP Providers
Exam N/A N/A
Lenses 24Months 24Months
Frames 24Months 24Months
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