2018 Sunnyvale Benefit Summary

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Vision
You are eligible for vision coverage through Vision Service Plan (VSP). VSP provides coverage for
eye exams and materials, such as lenses and frames.
Vision
VSP Vision VSP Vision Buy-Up
In-Network Out-of-Network In-Network Out-Of-Network
Examination
Benefit $15 copay up to $50 $15 copay up to $50
Frequency 1 x every 12
months
In-network
limitations apply
1 x every 12
months
In-network
limitations apply
Materials $15 copay See schedule below $15 copay See schedule below
Eyeglass Lenses
Single Vision Lens Fully Covered Up to $50 Fully Covered Up to $50
Bifocal Lens* Fully Covered Up to $75 Fully Covered Up to $75
Trifocal Lens* Fully Covered Up to $100 Fully Covered Up to $100
Frequency 1 x every 24
months
In-network
limitations apply
1 x every 12
months
In-network
limitations apply
Frames
Benefit $120 allowance Up to $70 $130 allowance Up to $70
Frequency 1 x every 24
months
In-network
limitations apply
1 x every 24
months
In-network
limitations apply
Contacts** (Elective)
Benefit Up to $120 (copay
waived; instead of
eyeglasses)
Up to $105
(in-network
limitations apply)
Up to $130 (copay
waived; instead of
eyeglasses)
Up to $105
(in-network
limitations apply)
Frequency 1 x every 24
months
In-network
limitations apply
1 x every 12
months
In-network
limitations apply
*No-lined lenses are not a covered benefit under this plan. When requested, the lenses will be covered up to the value of the lined lenses and you will
pay the additional cost.
**When you choose contacts instead of glasses, your $120/$130 allowance applies to the cost of your contacts and the contact lens exam (fitting and
evaluation). This exam is in addition to your vision exam to ensure proper fit of contacts.
Note: You may receive benefits when using non-VSP providers by submitting your claims directly to VSP. Reimbursements will be made as
indicated in the out-of-network schedule above. Find a VSP network doctor a r call (800) 877-7195.