Page 11 - MGC_group_TAA_Final_9-1-2017.pdf

HOW DOES MY PLAN WORK?
VSP CHOICE NETWORK
DAVIS NETWORK
VISION HEALTH COVERAGE
COPAY
IN-NETWORK REIMBURSEMENT
OUT-OF-NETWORK REIMBURSEMENT
IN-NETWORK REIMBURSEMENT
OUT-OF-NETWORK REIMBURSEMENT
EYE EXAMS BENEFITS
$10
100%
$39 Max
100%
$39 Max
LENSE BENEFITS
SIngle
$25
100%
$23 Max
100%
$48 Max
Bifocal
$25
100%
$37 Max
100%
$67 Max
Trifocal
$25
100%
$49 Max
100%
$86 Max
Lenticular
$25
100%
$64 Max
100%
$126 Max
CONTACT LENSES BENEFITS
Medically Necessary
$25
100%
$210 Max
100%
$210 Max
Elective
$25
$150 Max copay wavied
$100 Max copay wavied
$150 Max copay wavied
$100 Max copay wavied
FRAME BENEFITS
$25
$130 retail max + 20% off the balance
$46 Max
$130 retail max + 20% off the balance
$48 Max
Davis’ Tower deigner frame
$25
n/a
n/a
100%
$48 Max
Davis’ Premier designer frame
$25
n/a
n/a
100%
$67 Max
Fitting / Evaluation Fees
$25
15% discount
no discount
15% discount
no discount
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