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Summary Plan Description (SPD)
Co-payments and Schedule of Benefits
| Benefit |
Frequency (Based on service year) |
Co-payment |
Coverage from a VSP doctor |
Out-of-Network Reimbursement |
|
| Exam | 12 months | $5 | Covered in full. | Up to $45 allowance | |
| Prescription Eyewear – You may choose between glasses or contacts. When contact lenses are chosen you will be eligible for a frame twenty-four months from the date contact lenses were obtained. | |||||
| Lenses | 12 months | $10 (lenses and/or frame) | Single vision, lined bifocal and lined trifocal lenses are covered in full. |
Single vision up to $45
allowance Lined bifocal up to $65 allowance Lined trifocal up to $85 allowance |
|
| Frame – as provided by VSP | 24 months | $10 (lenses and/or frame) |
Covered up to $120
allowance |
Up to $47 allowance | |
| Contact Lenses* | 12 months |
|
Covered up to $105 allowance | Up to $105 allowance | |
|
*Your allowance applies to the cost of
your contact lens exam and your contact lenses. You’ll receive a 15
percent savings off the cost of your contact lens exam from a VSP doctor. Your
contact lens exam is in addition to your routine eye exam to check for eye
health risks associated with improper wearing or fitting of
contacts. You may get regular glasses (frames and lenses) twelve months after you get contact lenses. |
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