UL - 2023-24 Benefits Guide (FINAL) SP

VSP CHOICE NETWORK VISION PLAN

BENEFIT

IN-NETWORK

OUT-OF-NETWORK

FREQUENCY

Eye Exam

$10 copay

Up to $45 reimbursement

Every 12 months

Lenses Single Vision Lenses Bifocal Vision Lenses Trifocal Vision Lenses Lenticular Vision Lenses Standard Progressive Lenses

$25 copay $25 copay $25 copay $25 copay $0 copay

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

Every 12 months

Frames

$25 copay $150 allowance; 20% off balance over $150

Up to $70 reimbursement

Every 24 months

Contact Lenses Lenses Disposable Lenses Medically Necessary Lenses Laser Vision Correction (administered by LCA-Vision, Inc.) Principallasik.com 888.647.3937

$25 copay $150 allowance Covered in full after $25 copay You pay an average of $15 off the regular price and 5% off the promotional price. (In-Network Benefit Only) Glasses and Sunglasses - save an average of 20-25% off glasses or sunglasses from any VSP doctor within 12 months of your last covered vision exam.

Up to $105 reimbursement Up to $105 reimbursement Up to $210 reimbursement

Every 12 months

Not Covered

N/A

Additional Benefits

Not Covered

12 Months

Bi-Weekly Contributions (24-pay periods) Employee Only Employee + Spouse Employee + Child(ren) Employee + Family

$2.50 $5.00 $5.00 $8.00

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