Page 12 - Dentons 2021 Benefits Guide Hawaii
P. 12
VISION PLAN
VSP Choice Plan
New to Dentons 2021, you can choose from an extensive network of private practice optometrists,
ophthalmologists, and opticians, or from leading optical retailers, including (but not limited to)
Walmart and Sam’s Club. Services provided outside of the VSP provider network are offset against
a pre-determined allowance for services and supplies.
VSP Members also receive additional benefits including:
Access to eyeconic.com, VSP benefit integrated online retail store for eyeglasses, sunglasses,
and contact lenses
Additional $50 frame allowance on select brands including Calvin Klein, Chloe, Lacoste, Nike,
and DRAGON
Exclusive mail-in rebate savings on eligible contact lenses from $50-$200
Discounts on additional glasses and LASIK surgery
Benefits are payable once every 12 months for exams and lenses and once every 24 months for
frames.
Member Cost Reimbursable Amounts
Plan Summary (In-Network) (Out-of-Network)
Eye Examinations (once every 12 months) $10 copay $10 copay
Frames (once every 24 months) $150 allowance Up tp $70
Materials $25 copay N/A
Standard Plastic Lenses (once every 12 months) Up to
Single Vision $30
Bifocal Covered in full $50
Trifocal $65
Standard Progressive Lens Covered in full Up to $55
Premium Progressive Lens $95-$105 Up to $55
Lens Options:
UV Treatment & Tint $10
Photochromic $70-$82
Standard Polycarbonate $35 (adult)/children N/A
covered in full
Standard Anti-Reflective Coating $41
Polarized 20% off retail price
Contact Lens Options (once every 12 months): $0 copay
Conventional/Disposable $150 allowance Up to $124
Laser VisionCare Program 15% off retail price or 5%
PRK, LASIK, and Custom LASIK off promotional price N/A
Sign up at www.vsp.com to access claims history and detailed coverage information.
Vision Monthly Plan Premiums
Single $5.42
Single +1 $9.86
Family $15.10
12
VSP Choice Plan
New to Dentons 2021, you can choose from an extensive network of private practice optometrists,
ophthalmologists, and opticians, or from leading optical retailers, including (but not limited to)
Walmart and Sam’s Club. Services provided outside of the VSP provider network are offset against
a pre-determined allowance for services and supplies.
VSP Members also receive additional benefits including:
Access to eyeconic.com, VSP benefit integrated online retail store for eyeglasses, sunglasses,
and contact lenses
Additional $50 frame allowance on select brands including Calvin Klein, Chloe, Lacoste, Nike,
and DRAGON
Exclusive mail-in rebate savings on eligible contact lenses from $50-$200
Discounts on additional glasses and LASIK surgery
Benefits are payable once every 12 months for exams and lenses and once every 24 months for
frames.
Member Cost Reimbursable Amounts
Plan Summary (In-Network) (Out-of-Network)
Eye Examinations (once every 12 months) $10 copay $10 copay
Frames (once every 24 months) $150 allowance Up tp $70
Materials $25 copay N/A
Standard Plastic Lenses (once every 12 months) Up to
Single Vision $30
Bifocal Covered in full $50
Trifocal $65
Standard Progressive Lens Covered in full Up to $55
Premium Progressive Lens $95-$105 Up to $55
Lens Options:
UV Treatment & Tint $10
Photochromic $70-$82
Standard Polycarbonate $35 (adult)/children N/A
covered in full
Standard Anti-Reflective Coating $41
Polarized 20% off retail price
Contact Lens Options (once every 12 months): $0 copay
Conventional/Disposable $150 allowance Up to $124
Laser VisionCare Program 15% off retail price or 5%
PRK, LASIK, and Custom LASIK off promotional price N/A
Sign up at www.vsp.com to access claims history and detailed coverage information.
Vision Monthly Plan Premiums
Single $5.42
Single +1 $9.86
Family $15.10
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