Page 14 - 2015 Enrollment Guide
P. 14
2015 Employee
Beneits Program
Vision
VSP PPO Plan
Vision Service Plan (VSP)
has a large network of eye Vision Service Plan (VSP) has a large network of eye care providers.
care providers. You may also go to non-preferred providers, but you will need to
pay for services and then submit a claim form for the reimbursed
The information at left is allowances.
a summary only. Please
refer to your Evidence of Vision Service Plan (VSP)
Coverage for complete In-Network Out-of-Network
details of plan benefits, Exam
limitations, and exclusions. $10 copay Up to scheduled
allowance
Materials
$25 copay Up to scheduled
allowance
Lenses
Single lens No Charge after Up to scheduled
Bifocal lens materials copay allowance
Trifocal lens
Frames
$150 allowance plus $70 allowance
20% discount on excess
amount
Elective Contact Lens
$150 allowance $105 allowance
Beneit Frequency Limitations
Exams 12 months
Lenses 12 months
Contacts (in lieu of glasses) 12 months
Frames 24 months
14
Beneits Program
Vision
VSP PPO Plan
Vision Service Plan (VSP)
has a large network of eye Vision Service Plan (VSP) has a large network of eye care providers.
care providers. You may also go to non-preferred providers, but you will need to
pay for services and then submit a claim form for the reimbursed
The information at left is allowances.
a summary only. Please
refer to your Evidence of Vision Service Plan (VSP)
Coverage for complete In-Network Out-of-Network
details of plan benefits, Exam
limitations, and exclusions. $10 copay Up to scheduled
allowance
Materials
$25 copay Up to scheduled
allowance
Lenses
Single lens No Charge after Up to scheduled
Bifocal lens materials copay allowance
Trifocal lens
Frames
$150 allowance plus $70 allowance
20% discount on excess
amount
Elective Contact Lens
$150 allowance $105 allowance
Beneit Frequency Limitations
Exams 12 months
Lenses 12 months
Contacts (in lieu of glasses) 12 months
Frames 24 months
14
