JC - 2024 Employee Benefits Guide - (FINAL 11.28.2023) SPR

EYECHOICE FOCUS VSP CHOICE NETWORK PLAN

BENEFIT

IN-NETWORK

OUT-OF-NETWORK

Eye Exam with Dilation Contact Lens Exam

$10 copay Member cost up to $60

$10 copay In-Network only

Hardware

$25 copay

$25 copay

Frequency Exam

12 months 12 months 24 months 12 months

12 months 12 months 24 months 12 months

Lenses Frames Contact Lenses

Frames

$100 allowance

Up to $70

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

Covered 100% Covered 100% Covered 100% Covered 100%

Up to $30 Up to $50 Up to $65 Up to $100

Contact Lenses in lieu of Glasses Medically Necessary Elective

Covered 100% $115 allowance

Up to $210 Up to $105

Dependent Age Limit

To age 31 (coverage terminates date dependent turns 31)

•

•

•

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

9