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

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

18 2018 ToTal RewaRds Guide