Page 15 - 2016 Open Enrollment Non-Union
P. 15
Hussmann Corporation
To find a VSP doctor,
visit www.vsp.com or call
Vision 800.877.7195
The vision plan is offered through vision service plan (VSP) utilizing
the choice network. Just a reminder, there are no ID cards issued for
the vision plan. Group numbers are available on the beneit directory.
Out-of-Network
Description In-Network Reimbursement
WellVision Exam * (Every calendar year)
Focuses on your eyes $10 copay Up to $45
and overall wellness
Frame Every other calendar year
$150 allowance for a $25 copay Up to $70
wide selection of frames
+ 20% off the amount
over your balance
Lenses (Every calendar year)
Single vision, lined $25 copay Single: up to $30
bifocal, and lined trifocal Lined bifocal: up to $50
lenses Lined trifocal: up to $65
Lens Options (Every calendar year)
Standard progressive Standard Up to $50
lenses progressive: $55
Premium progressive Premium
lenses progressive: Diabetic Eyecare Plus
Custom progressive $95—$105 Program
lenses Custom progressive: In-network vision services related to type
Average of 20-25% $150—$175 1 and 2 diabetes are available for a $20
off other lenses
options copay with no frequency limitations. Ask
Contacts—Instead of glasses (Every calendar year) your VSP provider for details.
$150 allowance for Contacts itting and Up to $105
contacts, copay does evaluation is covered up
not apply; contacts to $60
lens exam (itting and
evaluation)
Discounts available (in-network only): 20 percent off additional glasses and Contribution Rates
sunglasses, including lens options, from any VSP doctor within 12 months of your Monthly Employee
last WellVision exam. Average of 15 percent off the regular price or 5 percent off Vision Plan Contribution
the promotional price for laser vision correction at contracted facilities. Employee (Ee)
Note: frequency is based on a calendar year basis: this means you can get a new exam $4.89
starting every January 1, as opposed to 12 months from the date of your last exam. Ee + Spouse $9.77
Ee + Child(ren) $10.46
* If you are enrolled on Hussmann’s medical plan, a WellVision exam is covered under
preventive care services at 100 percent. Family $16.71
15
To find a VSP doctor,
visit www.vsp.com or call
Vision 800.877.7195
The vision plan is offered through vision service plan (VSP) utilizing
the choice network. Just a reminder, there are no ID cards issued for
the vision plan. Group numbers are available on the beneit directory.
Out-of-Network
Description In-Network Reimbursement
WellVision Exam * (Every calendar year)
Focuses on your eyes $10 copay Up to $45
and overall wellness
Frame Every other calendar year
$150 allowance for a $25 copay Up to $70
wide selection of frames
+ 20% off the amount
over your balance
Lenses (Every calendar year)
Single vision, lined $25 copay Single: up to $30
bifocal, and lined trifocal Lined bifocal: up to $50
lenses Lined trifocal: up to $65
Lens Options (Every calendar year)
Standard progressive Standard Up to $50
lenses progressive: $55
Premium progressive Premium
lenses progressive: Diabetic Eyecare Plus
Custom progressive $95—$105 Program
lenses Custom progressive: In-network vision services related to type
Average of 20-25% $150—$175 1 and 2 diabetes are available for a $20
off other lenses
options copay with no frequency limitations. Ask
Contacts—Instead of glasses (Every calendar year) your VSP provider for details.
$150 allowance for Contacts itting and Up to $105
contacts, copay does evaluation is covered up
not apply; contacts to $60
lens exam (itting and
evaluation)
Discounts available (in-network only): 20 percent off additional glasses and Contribution Rates
sunglasses, including lens options, from any VSP doctor within 12 months of your Monthly Employee
last WellVision exam. Average of 15 percent off the regular price or 5 percent off Vision Plan Contribution
the promotional price for laser vision correction at contracted facilities. Employee (Ee)
Note: frequency is based on a calendar year basis: this means you can get a new exam $4.89
starting every January 1, as opposed to 12 months from the date of your last exam. Ee + Spouse $9.77
Ee + Child(ren) $10.46
* If you are enrolled on Hussmann’s medical plan, a WellVision exam is covered under
preventive care services at 100 percent. Family $16.71
15
