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Vision Plan 10

Vision Service Plan

ABC Company offers you vision care coverage through Vision Service Plan (VSP). VSP allows you to
receive vision care services from any provider you wish. When you access vision care from VSP network
providers, most eligible services are covered at 100%. Vision care accessed from out-of-network providers
is reimbursed to the patient up to the maximums noted below.

Plan Features Vision Service Plan

In-Network Out-of-Network
Providers When you obtain vision care services from a VSP provider,
you receive a higher level of benefits
Annual Deductible $20 copay per individual

Vision Care Services
Examination Covered at 100%; Covered up to $45
(Once Every 12 Months) subject to deductible
Glasses
Lenses Covered at 100%; Covered up to the following
1
(Once Every 12 Months) subject to deductible maximums:
Single Vision: $30
Bifocal: $50
Trifocal: $65
Lenticular: $100
Frames Covered at 100% up to $130 retail; Covered up to $70
(Once Every 12 Months) subject to deductible 2

Contact Lenses
Medically Necessary Covered at 100% Covered up to $210

Elective Covered up to $130 Covered up to $105
(Once Every 12 Months in Lieu of
Frames and Lenses)
Value Added Discounts
Laser VisionCare SM VSP has contracted with many of the nation’s finest laser surgery facilities and
doctors, offering you a discount for PRK and LASIK surgeries through
contracted laser centers. Visit VSP’s website at www.vsp.com to
learn more about this program.
Prescription Glasses Receive 20% savings when you purchase non-covered pairs of prescription
glasses, including prescription sunglasses from the same VSP doctor within
12 months of your last eye exam.

1 Optional items such as tinted, photochromic, coated, and progressive lenses are not covered, but are available through
VSP providers at a discount.
2 Amounts exceeding the retail allowance receive a 20% discount from VSP providers.