Page 14 - GSF Sample Guide

Vision Plan Highlights

Principal | PPO Vision Plan
The Principal vision plan utilizes the VSP Choice Network of Providers and 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 ap-
pointment and will be required to file an itemized claim with Principal.

Principal
PPO Plan

Network Non-Network

Vision Benefits
Copay
- Examination $10 Copay N/A
- Prescription Glasses $25 Copay N/A

Examination (Every X Months) 100% Up to $45 Reimbursement
Lenses (Every 12 Months)
− Single Vision 100% Up to $30 Reimbursement
− Bifocal 100% Up to $50 Reimbursement
− Trifocal 100% Up to $65 Reimbursement
− Lenticular 100% Up to $100 Reimbursement

Frames (Every 24 Months) $130 Allowance Up to $70 Reimbursement
Contact Lenses (Every 12 Months) In Lieu of Frames and Lenses
− Cosmetic / Elective $60 copay, $130 Allowance Up to $105 Reimbursement
− Medically Necessary $25 copay Up to $210 Reimbursement
Laser Vision Correction Discounts through Not Covered
National Lasik Network
Tier You Pay Per Paycheck
Employee $.79
Employee + spouse $4.91
Employee + child(ren) $5.45
Employee + family $10.50

Finding a Vision Provider
• Principal/VSP: Go to www.vsp.com & select the “Choice Network” or call (800) 877-7195
• The VSP Vision network includes access to independent ophthalmologists and optometrists, as
well as Costco

14 Employee Benefits