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VSP Network Plan

VSP offers one of the nation's largest networks of independent When members visit a VSP network provider they'll get:
providers. With 91 % of VSP doctors offering early morning, • 20% off remaining frame balance
evening or weekend hours, members can visit a provider on their • 20% off non-covered complete prescription glasses
schedule. Find VSP network providers at vsp.com. • 20-25% off non-covered lens options such as UV coating and
polycarbonate lenses
C'osO T-"Visionworks· eyec-onic • 15% average off retail for LASIK or PRK laser eye correction, or
DflT 5% off promotional price, through a VSP provider
• $20 on featured frame brands

Based on applicable laws, reduced costs may vary by doctor location.

What the plans pay in-network / out-of-network
Deductible Choose between $10 exam & $25 materials OR $15 exam & $15 materials
Annual eye exam 100% I Up to $45
Single vision 100% I Up to $30
Bifocal 100% I Up to $50
Trifocal 100% I Up to $65
Plan2

Contacts $130 / Up to $105

Benefit frequencies
Exam-lens-frame 12-12-24 12-12-12
Monthly rates

Employee $8.76 $9.60
Employee + spouse $18.96 $20.68
Employee + child(ren) $15.36 $16.76
Family $25.52 $27.80
Upgrade to $150 / $150 lens and frame allowances
I I

Employee $9.12 $9.96
Employee + spouse $19.68 $21.40
Employee + child(ren) $15.88 $17.40
Family $26.44 $28.88
All rates are valid for policies with an effective date through 12/31/22, and are guaranteed for four years.
Voluntary plans may be set to align with the Section 125 plan year.
Limitations

Please refer to the Certificate of Insurance for a complete 11st of C(l,lered IJ'(Cedures. Check for avallallllty • Medical or surgical treatment of the eyes.
In your state. Cove expenses will not Include, and no benefits will be payatle for: • Cont lens modfflcatlon, pollsting or cleaning.
• In netwokoontact lens exam-fit & follow up cost Is capped at$60 (except In WA). • The refitting of contact lenses aftS' the Initial 90-day flllng period.
• Vision examinations, lenses and frames more than the frequency as Indicated on the plan summary page. • Cont lens Insurance policies or service contracts.
• Ser.ices and/or mattrlals not specically Inducted In the Schedule as covered Plan Benefits. • Additional office llislts associated with contact lens pathology.
• Plano lenses �enses v.1th refracHve correion of less than plus or minus .50 cloptS') except as • Local, state and/or federal taxe, except where law requires us to pay.
specfflcally allowed In the frames benefit secHon of the Plan Benefits. • Qwered persons may be required to purchase a membi:Jshlp at certain retail locations before
• Ser.ices or materials that are cosmic, Including piano contact lenses to change eye color and aocesslng plan benefits.
atlstlcally painted oonta:t l1:11ses. • Plans not avallatle In RI.
• Two pairs of glasses In lieu of ljfocaJs. • Plans are not available In FL for groups with less than 51 lives.
• Replacement of spectae lenses, frames, and/or contact lenses furnished under this i:tin that are lost or
damaged, exce at the normal lntelvs when services are otherwise available. • Specffi: plans not listed In this brochure are available for MA and MO.
• Orthoptlcs or vision training and any assoted supplemental testing. Consult your sales representative regarclng plan avallatlllty In the states of MA, WA and MO.