Page 11 - Walter Robbs 2018 Benefit Guide

Voluntary Vision Benefits
Group # 30020000

VSP Signature Vision Plan
Voluntary Vision
Network Provider Non-network
Provider
Copayments:

Eye Exam $10 Covered up to $50

Materials $30 See below
Frequency of Services:

Eye Exam Once per 12 Months

Lens Once per 12 Months

Frames Once per 24 Months

Once per 12 Months
Contact Lenses
(in lieu of frames & lenses)

Materials Benefits:

Single Vision Covered in Full* Covered up to $50*

Bifocal Lenses Covered in Full* Covered up to $75*

Trifocal Lenses Covered in Full* Covered up to $100*

Lenticular Lenses Covered in Full* Covered up to $125*

Covered up to $130*
Frames (20% off any amount Covered up to $70*

over $130 allowance)

Elective Contact Lenses Covered up to $130* Covered up to $105*

Medically Necessary Contact Lenses Covered in Full* Covered up to $210*

*Less any applicable copayment
Service frequency is based on date of last service.

10 |