Page 15 - FSSI EE Guide 07-20 - CA

VSP | Vision Plan
FSSI provides vision coverage through VSP. You can see an VSP in-network provider or an out-of-network provider,
however, your costs will be lower if you visit an in-network provider. If you visit an in-network provider you will be
responsible for a copayment at the time of your service. If you receive services from an out-of-network doctor, you
will pay all costs at the time of service and submit a claim for reimbursement.

VSP
Plan Name PPO
Network Name VSP Choice Non-Network
Vision Benefits
Copay
- Examination $10 Copay N/A
- Materials $25 Copay N/A
Examination (Every 12 Months) No Charge Up to $45 Reimbursement
Lenses (Every 12 Months)
- Single Vision No Charge Up to $30 Reimbursement
- Bifocal No Charge Up to $50 Reimbursement
- Trifocal No Charge Up to $65 Reimbursement
Frames (Every 24 Months) $130 Allowance, then 20% Discount Up to $70 Reimbursement
$150 Featured Frame Allowance
$70 Costco Frame Allowance
Contact Lenses (Every 12 Months) (in lieu of frames and lenses)
- Cosmetic / Elective $130 Allowance Up to $105 Reimbursement
- Medically Necessary No Charge Up to $210 Reimbursement
Laser Vision Correction Discounts Apply Not Covered

Finding a Vision Provider
Go to www.vsp.com. Refer to the “VSP Choice” network.

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.

Additional Discounts Available
• Glasses and Sunglasses: Get an extra $20 to spend on featured frame brands. Go to
www.vsp.com/offers for details. You’ll also get a 20% savings on additional glasses and
sunglasses, including lens enhancements, from any VSP provider within 12 months of your last
examination.
• Retinal Screening: Spend no more than a $39 copay on routine retinal screening as an
enhancement to a vision examination.
• Laser Vision Correction: You’ll receive an average 15% off the regular price, or 5% off the
promotional price; discounts are only available from contracted facilities.