Benefit Guide - Circles

VISION BENEFITS

Regular eye examinations can not only determine your need for corrective eye wear but also may detect general health problems in their earliest stages. Protection for the eyes should be a major concern to everyone.

VSP CHOICE NETWORKPLAN

BENEFIT

IN-NETWORK

OUT-OF-NETWORK

Eye Exam

$10 copay

Reimbursed up to $39

Prescription Glasses

$25 copay

See below

Frequency Exam Lenses Contact Lenses Frames

Every calendar year Every calendar year Every calendar year Every other calendar year

$130 allowance 80% over $130 allowance

Frames

Reimbursed up to $46

Lenses Single Vision Lenses Bifocal Vision Lenses Trifocal Vision Lenses Lenticular Vision Lenses

Reimbursed up to $23 Reimbursed up to $37 Reimbursed up to $49 Reimbursed up to $64

Included in Prescription Glasses

Contact Lenses Elective

$130 allowance No charge 15% off UCR

Reimbursed up to $100 Reimbursed up to $210 In-Network Only

Medically Necessary Evaluation and Fitting

BI-WEEKLY CONTRIBUTIONS

Employee Employee + Spouse Employee + Child(ren) Employee + Family

$1.74 $3.49 $5.59 $6.63

For additional information, please refer to your detailed plan summary. In the event of a discrepancy, the carrier Plan Document shall prevail.

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