Page 14 - United Capital EE Benefit Guide 2019-2020

VISION INSURANCE

VSP | PPO VISION PLAN
The VSP 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 81,000 access points
nationwide. VSP also contracts with Costco Optical, Visionworks, Walmart, Sam’s Club, and other affiliate retail providers. Please
note, benefits may vary at affiliate locations.

VSP
PPO
Network Name Network Non-Network
VISION BENEFITS
Copay
• Examination $10 Copay N/A
• Materials $10 Copay N/A
Examination (Every 12 Months) 100% Covered Up to $45 Reimbursement
Lenses (Every 12 Months)
• Single Vision 100% Covered Up to $30 Reimbursement
• Bifocal 100% Covered Up to $50 Reimbursement
• Trifocal 100% Covered Up to $65 Reimbursement
• Lenticular 100% Covered Up to $100 Reimbursement
Frames (Every 12 Months) $130 Allowance, then 20% Discount Up to $70 Reimbursement
Contact Lenses (Every 12 Months) (in lieu of frames and lenses)
• Cosmetic / Elective $130 Allowance Up to $105 Reimbursement
• Medically Necessary 100% Covered Up to $210 Reimbursement
Laser Vision Correction Average 15-20% Discount or 5% Not Covered
Discount Off Promotional Price -
Includes PRK, LASIK, and Custom LASIK
Additional Glasses and Sunglasses 20% Discount Off Unlimited Additional N/A
Pairs of Prescription Glasses and/or
Non-Prescription Sunglasses

LENS ENHANCEMENTS:
The most popular lens enhancements are covered after a copay, saving you an average of 20-25%. Ask your VSP provider for
special pricing on additional lens enhancements.

FINDING A DENTAL PROVIDER:
Go to www.vsp.com or call (800) 877-7195. Refer to the “VSP Choice” network when prompted.

14 UNITED CAPITAL 2019-2020