Vision Coverage

This page outlines the coverage of your Vision Benefits with Vision Service Plan. Should you need them, your
Plan's Group Numbers are:
#00460200-0003 (Active) - download your Vision Plan highlights
#00460200-0004 (Retiree) - download your Vision Plan highlights

Plan Highlights

PLAN FEATURES	FREQUENCY (1)	COPAY	VSP Network Provider	Out-of-Network
Eye Exam
	12 months	$10	Covered	Covered up to $45.
Lenses (2)
	24 months	$25 for lenses and frames.	Covered	single vision Covered up to $45
			Single vision, lined bifocal, lined trifocal lenses.	Bifocal Covered up to $65
			Polycarbonate lenses for dependent children.	Trifocal Covered up to $85
				Lenticular Covered up to $125
Frame
	24 months  Once every 12 months for children age 14 and under.	$25 for lenses and frames.	$120 retail frame allowance plus 20% off of any out-of-pocket costs.	Covered up to $47
Contact Lenses (3)
Medically Necessary (4)	12 months	None	Covered.	Covered up to $210.
Elective	12 months	None	Covered up to $105. (5)	Covered up to $105.
Laser Vision Correction(6)
	N/A	N/A	Discounted services	None

(1) Based on your last date of service.
(2) Your plan provides a 20 percent discount on non-covered complete pairs of prescription glasses when provided by a VSP doctor.
(3) Patients choosing contacts use their eligibility for a frame and lenses.
(4) Medically necessary contact lenses must be prescribed for certain conditions which prevent you from wearing eyeglasses and must be pre-approved by VSP.
(5) Your plan also includes a 15 percent discount off the cost of your contact lens exam (fitting & evaluation) when you receive contact lens services from a VSP doctor.
(6) Discounted laser vision correction surgery (PRK and LASIK) is available through VSP contracted laser centers. Program availability may vary based on location and regulatory approval.

Other Information

www.vsp.com                (800) 877-7195

Download your VSP Highlights  -   Actives     Retirees