Page 10 - 2022 Infoblox Benefits Guide

Spending Income Optional
Vision
Contents Eligibility Medical Contributions Dental V ision Accounts Protection Benefits Contacts

Vision Plan

Healthy eyes and clear vision are an important part of your overall health and quality of life. This coverage is optional.
You do not have to be enrolled in medical coverage to elect vision coverage or cover the same dependents under
medical and vision. However, you must cover the same dependents under dental and vision.

Vision Plan
PARTICIPATING PROVIDER NON-PARTICIPATING PROVIDER
You Pay Reimbursement
Cost
Exam $10 Up to $50 after $10 copay
Based on benefit schedule
Materials $25
after $25 copay
Covered Services – Lenses
Single Lenses $0 after copay Up to $50 after copay
Bifocals $0 after copay Up to $75 copay
Trifocals $0 after copay Up to $100 copay
Frames $150 allowance after copay Up to $70 copay
Covered Services – Contacts in lieu of Frames/Lenses
Contacts - Medically Necessary $0 after copay Up to $210 after copay
Contacts - Elective $130 allowance after copay Up to $105 copay
Benefit Frequency
Exams Once every 12 Months Once every 12 Months
Lenses Once every 12 Months Once every 12 Months
Frames Once every 24 Months Once every 24 Months
Contacts Once every 12 Months Once every 12 Months
Computer Visioncare (Employee-Only Coverage)
Evaluates your needs related to $10 for exam Once every
Computer Vision Exam
computer use and glasses 12 Months
• $150 allowance for a wide
selection of frames
• $170 allowance for featured Combined Once every
Frame
frame brands with exam 24 Months
• 20% savings on the amount over
your allowance
Single vision, lined bifocal, lined Combined Once every
Lenses
trifocal, and occupational lenses with exam 12 Months
Visit VSP.com for a list of participating providers.
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