Page 7 - 2015 NVW Open Enrollment Guide

New Vision Wilderness Therapy

Vision
Vision

Beneits VSP Provider Out-of-Network
Employer Funded
Frequency 12 Months
EXAM Copayment $10
Plan Pays Covered in full Up to $40 allowance
Frequency 12 Months
Copayment $25 (Applicable to lenses and frames)
Single vision, lined Single vision up to $40
bifocal, lined trifocal, allowance,
LENSES and lenticular lenses are lined bifocal up to $60
allowance,
Plan Pays covered in full * lined trifocal up to $80
allowance
lined lenticular up to $80
allowance
Frequency 12 Months
Frame Retail Cost Structure (3 to 4 times wholesale cost)
FRAMES Allowance
Plan Pays Covered up to $130 Up to $45 allowance
allowance
Frequency 12 Months
Covered Up to 4 boxes plus itting Up to $105
Contact Lenses and evaluation covered in
Selection full after copay
CONTACT Non-selection Up to $105 (copay Up to $105
LENSES Contacts waived)

Necessary Covered in full after Up to $210
Contacts copay

* For additional lens options, please refer to the vision beneit summary

Bi-Weekly Contributions

Employee Only $1 .94
Employee + Spouse $5 .91
Employee + Child(ren) $6 .28
Employee + Family $8 .46

7