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Vision Benefits

VSP | 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 an out-of-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
Plan Features
Vision
In-Network Out-of-Network
Network Name
(VSP Signature Network) (Reimbursement)
Vision Benefits

Copay
- Examination $10 Copay Up to $45
- Materials $25 Copay N/A

Examination (Every 12 Months) 100%, after copay $45 Benefit
Lenses (Every 12 Months)
- Single Vision 100%, after copay Up to $30
- Bifocal 100%, after copay Up to $50
- Trifocal 100%, after copay Up to $65
- Lenticular 100%, after copay Up to $100

Frames( Every 24 Months) $130 Benefit, Up to $70
Then 20% Discount
Contact Lenses (Every 12 Months) In Lieu of Frames and Lenses

- Cosmetic / Elective $130 Benefit Up to $105
Laser Vision Correction Discounts Apply Not Covered
*The above information is a summary only. Please refer to your Evidence of Coverage for complete details of Plan benefits, limita-
tions and exclusions.

Note: VSP is the largest network of private-practice eye care doctors in the industry. VSP’s network includes 37,000 access
points nationwide. Most of the U.S. population lives within four miles of a VSP provider.

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