Page 13 - Surfline Benefits Guide 2017

Vision

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 50,000 access points nationwide. VSP
also contracts with Costco Optical, Eye Care Centers of America / Visionworks, and other affiliate retail providers. Please note, benefits may
vary at affiliate locations.

VSP
Vision Plan

Network Name VSP Signature Non-Network
VISION BENEFITS
Copay
• Examination $20 Copay N/A
• Materials $20 Copay N/A
Examination (Every 12 Months) No Charge Up to $50 Reimbursement
Lenses (Every 12 Months)
• Single Vision No Charge Up to $50 Reimbursement
• Lined Bifocal No Charge Up to $75 Reimbursement
• Lined Trifocal No Charge Up to $100 Reimbursement
• Progressive $50-$160 Copay Up to $75 Reimbursement
• Tints No Charge Up to $5 Reimbursement
• Lens Enhancements Average 35-40% Savings N/A
Frames (Every 12 Months) $130 Allowance, then 20% Discount Up to $70 Reimbursement
On Amounts Over Allowance
$150 Allowance on Featured Brands
Contact Lenses (Every 12 Months) (in lieu of frames and lenses)
Up to $60 Copay, $130 Allowance Up to $105 Reimbursement
Laser Vision Correction Discounts Apply Not Covered

Finding a Vision Provider

Call (800) 877-7195 or go to www.vsp.com and select “Find a Doctor.” Refer to the “VSP Signature” network when
prompted.

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