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A LOOK AT YOUR
      VSP VISION COVERAGE


      SEE HEALTHY AND LIVE HAPPY                           BENEFIT      DESCRIPTION                        COPAY
                                                                      YOUR COVERAGE WITH A VSP PROVIDER
      WITH HELP FROM MLB OFFICE
                                                          WELLVISION     Focuses on your eyes and overall
      OF THE COMMISSIONER AND                             EXAM           wellness                           $10
                                                                         Every calendar year
      VSP.                                                PRESCRIPTION GLASSES                              $25

                                                                         $140 featured frame brands
      As a VSP® member, you get personalized care                        allowance
                                                                         $120 frame allowance
      from a VSP network doctor at low out-of-pocket                     20% savings on the amount over  Included in
      costs.                                              FRAME          your allowance               Prescription Glasses
                                                                         $65 Walmart®/Sam's Club®/Costco®
                                                                         frame allowance
      VALUE AND SAVINGS YOU LOVE.                                        Every other calendar year
      Save on eyewear and eye care when you see a                        Single vision, lined bifocal, and
      VSP network doctor. Plus, take advantage of                        lined trifocal lenses           Included in
      Exclusive Member Extras for additional savings.     LENSES         Impact-resistant lenses for  Prescription Glasses
                                                                         dependent children
      PROVIDER CHOICES YOU WANT.                                         Every other calendar year
      With an average of five VSP                                        Standard progressive lenses        $0
      network doctors within six                                         Premium progressive lenses      $80 - $90
      miles of you, it’s easy to find a                   LENS           Custom progressive lenses       $120 - $160
                                                          ENHANCEMENTS
                                                                         Average savings of 40% on other
      nearby in-network doctor. Plus,                                    lens enhancements
      maximize your coverage with                                        Every other calendar year
      bonus offers and additional                                        $120 allowance for contacts; copay
      savings that are exclusive to                       CONTACTS       does not apply
      Premier Program locations.                          (INSTEAD OF    Contact lens exam (fitting and  Up to $60
                                                          GLASSES)       evaluation)
      Like shopping online? Go to eyeconic.com and                       Every other calendar year
      use your vision benefits to shop over 50 brands                    Retinal screening for members with  $0
      of contacts, eyeglasses, and sunglasses.                           diabetes
                                                                         Additional exams and services for  $20 per exam
      QUALITY VISION CARE YOU NEED.                                      members with diabetes, glaucoma,
      You’ll get great care from a VSP network doctor,                   or age-related macular
      including a WellVision Exam®—a comprehensive                       degeneration.
      exam designed to detect eye and health              PRIMARY  SM    Treatment and diagnoses of eye
                                                          EYECARE
                                                                         conditions, including pink eye,
      conditions.                                                        vision loss, and cataracts available
                                                                         for all members.
                                                                         Limitations and coordination with
      PROVIDER NETWORK:
                                                                         your medical coverage may apply.
      VSP Signature
                                                                         Ask your VSP doctor for details.
      EFFECTIVE DATE:                                                    As needed
      01/01/2021                                                       Glasses and Sunglasses
                                                                         Extra $20 to spend on featured frame brands. Go to
                                                                         vsp.com/offers for details.
                                                                         30% savings on additional glasses and sunglasses,
                                                                         including lens enhancements, from the same VSP provider
                                                                         on the same day as your WellVision Exam. Or get 20%
                                                                         from any VSP provider within 12 months of your last
                                                                         WellVision Exam.
                                                          EXTRA
                                                          SAVINGS      Routine Retinal Screening
                                                                         No more than a $39 copay on routine retinal screening
                                                                         as an enhancement to a WellVision Exam
                                                                       Laser Vision Correction
                                                                         Average 15% off the regular price or 5% off the
                                                                         promotional price; discounts only available from
                                                                         contracted facilities
                                                                         After surgery, use your frame allowance (if eligible) for
                     Contact us:                                         sunglasses from any VSP doctor
                                                                YOUR COVERAGE WITH OUT-OF-NETWORK PROVIDERS
             800.877.7195 or vsp.com
                                                          Get the most out of your benefits and greater savings with a VSP network
                                                          doctor. Call Member Services for out-of-network plan details.
      ©2021 Vision Service Plan. All rights reserved.     VSP guarantees coverage from VSP network providers only. Coverage information is subject to change.
      VSP, VSP Vision care for life, Eyeconic, and WellVision Exam are registered trademarks,
      and VSP Diabetic Eyecare Plus Program is a service mark of Vision Service Plan.  In the event of a conflict between this information and your organization’s contract with VSP, the
      All other brands or marks are the property of their respective owners. 45943 VCCM  terms of the contract will prevail. Based on applicable laws, benefits may vary by location. In the state
                                                          of Washington, VSP Vision Care, Inc., is the legal name of the corporation through which VSP does

                                                          business.
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