Page 20 - Ches User's Guide 2018 v1.4
P. 20

Vision Plan




               Vision insurance is offered through the VSP vision plan. By enrolling in the vision plan
               through Chesapeake, you and your dependents will receive value and savings on eye

               exams and eyewear. VSP has one of the largest networks of providers throughout the
               U.S. To find a provider near you, visit vsp.com or call 1-800-877-7195.



                BASIC COVERAGE (from a VSP Preferred Provider)    PREMIUM COVERAGE (from a VSP Preferred Provider)
                WellVision® Exam                                  WellVision® Exam
                Focuses on your overall eye health and wellness   Focuses on your overall eye health and wellness
                n   $10 copay, every calendar year                n   $5 copay, every calendar year
                Prescription Glasses                              Prescription Glasses
                Lenses                                            Lenses
                n   $10 copay, every calendar year                n   $10 copay, every calendar year
                n   Single vision, lined bifocal and trifocal lenses  n   Single vision, lined bifocal, trifocal and progressive lenses
                n   Polycarbonate lenses for dependent children   n   Polycarbonate lenses for dependent children
                Frames                                            Frames
                n   $150 allowance for wide selection of frames   n   $150 allowance for wide selection of frames
                n   $170 allowance for featured frames            n   $170 allowance for featured frames
                n   20% off amount above your allowance           n   20% off amount above your allowance
                – oR –                                            – ANd –
                Contact Lenses                                    Contact Lenses
                    $210 allowance for contacts and contact lens exam (fitting      $400 allowance for contacts and contact lens exam (fitting
                n                                                 n
                  and evaluation)                                   and evaluation)
                Diabetic Eye Care                                 Diabetic Eye Care
                Services related to diabetic eye disease, glaucoma, and age   Services related to diabetic eye disease, glaucoma, and age
                related macular degeneration (AMd). Retinal screenings for   related macular degeneration (AMd). Retinal screenings for
                eligible members with diabetes. limitations may apply.  eligible members with diabetes. limitations may apply.
                2017 MONTHLY PREMIUM                              2017 MONTHLY PREMIUM
                Employee Only                      $9.62          Employee Only                      $25.90
                Employee + Spouse                  $17.50         Employee + Spouse                  $47.20
                Employee + Child(ren)             $18.36          Employee + Child(ren)              $49.50
                Employee + Family                 $28.32          Employee + Family                  $76.38






















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