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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
t www.vsp.com or call (800) 877-7195.