Page 12 - NEW ICON GUIDE (PORTRAIT)

Vision Insurance

VSP | PPO Vision Plan
The VSP Preferred Provider Organization (PPO) vision plan provides professional vision care and high quality lenses and frames through a broad
network of optical specialists. You will receive richer benefits if you utilize a network provider. If you utilize a non-network provider, you will be
responsible to pay all charges at the time of your appointment and will be required to file an itemized claim with VSP.

VSP has the largest network of private-practice eye care doctors in the industry. VSP’s network includes 50,000 access points nationwide. VSP
also contracts with Costco Optical, Visionworks, and other affiliate retail providers. Please note, benefits may vary at affiliate locations.

VSP
Plan Name PPO

Network Name VSP Signature Non-Network
Vision Benefits
Copay
- Examination $10 Copay N/A
- Materials $25 Copay N/A

Examination (Every 12 Months) No Charge after Exam Copay Up to $50 Reimbursement
Lenses (Every 12 Months)
- Single Vision No Charge after Materials Copay Up to $50 Reimbursement
- Lined Bifocal No Charge after Materials Copay Up to $75 Reimbursement
- Lined Trifocal No Charge after Materials Copay Up to $100 Reimbursement
- Polycarbonate (Children) No Charge after Materials Copay Not Covered
- Progressive Lenses $50-$160 Copay Up to $75 Reimbursement
Frames (Every 24 Months, and $160 Allowance Up to $70 Reimbursement
12 Months for Children) $180 Allowance for Featured Frames
20% Savings Over Allowance
$90 Allowance for Costco
Contact Lenses (Every 12 Months) In Lieu of Frames and Lenses
- Cosmetic / Elective $160 Allowance Up to $105 Reimbursement
Laser Vision Correction Discounts Apply (See Below) Not Covered
KidsCare Plan (up to age 26) Exam: 2 Every 12 Months
Frames: Every 12 Months
Contributions Your Pay Per Pay Period
Employee Only $3.33
Employee + One $6.65
Employee + Family $10.70

Extra Savings:
• Extra $20 to spend on featured frame brands. Go to www.vsp.com/specialoffers for details.
• 30% savings on additional glasses and sunglasses, including lens enhancements, from the same VSP provider on the same day as your
examination. Or get 20% from any VSP provider within 12 months of your examination.
• No more than a $39 copay on routine retinal screening as an enhancement to an examination.
• Average 15% off the regular price, or 5% off the promotional price of Laser Vision Correction. Discounts are only available from contracted
facilities. After surgery, use your frame allowance (if eligible) for sunglasses from any VSP doctor.

Finding a Vision Provider
Go to www.vsp.com or call (800) 877-7195. Refer to the VSP Signature network when prompted.

12