Page 14 - Moonwell Studios Benefit Guide

Vision Plan

Guardian VSP | Vision Plan
Moonwell Studios provides vision coverage through Guardian with the VSP network. You can see a 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 ser-
vices from an out-of-network doctor, you will pay all costs at the time of service and submit a claim for reimburse-
ment.

Guardian VSP
Plan Name PPO

Network Name VSP Network Non-Network
Vision Benefits
Copay
- Examination $10 Copay N/A
- Materials $10 Copay N/A
Examination (Every 12 Months) No Charge Up to $39 Reimbursement

Lenses (Every 12 Months)
- Single Vision No Charge Up to $23 Reimbursement
- Bifocal No Charge Up to $37 Reimbursement
- Trifocal No Charge Up to $49 Reimbursement

Frames (Every 12 Months) $150 Benefit Up to $46 Reimbursement
Contact Lenses (Every 12 Months) (in lieu of frames and lenses)
- Cosmetic / Elective $150 Benefit Up to $100 Reimbursement
Laser Vision Correction Discounts Apply Not Covered

Finding a Vision Provider
Go to www.guardiananytime.com/fpapp/FPWeb/
Refer to the Vision VSP network

The VSP network includes access to independent ophthalmologists and
optometrists, as well as Costco and Walmart.

14 Employee Benefits