VISION PLAN C

Maximum Annual Benefits
  • Examination - once in each 12-month period.
  • Lenses - once in each 12-month period.
  • Frames - once in each 12-month period.
Co-payment Varies from $0 to $15 depending on the Plan chosen by your employer.
Benefits
Services from a VSP Participating Provider*
 
  • Examination
  • Single Vision Lenses
  • Bifocal Lenses
  • Trifocal Lenses
  • Lenticular Lenses
  • Frame
  • Contacts
  • Paid in full
  • Paid in full
  • Paid in full
  • Paid in full
  • Paid in full
  • Frame allowance of $130 plus 20% discount on any frame overage cost.
  • Contact allowance of $120 which applies to the contact lens exam (if needed) and materials.
Benefits
Services from a Non-Participating Provider
 
  • Examination
  • Single Vision Lenses
  • Bifocal Lenses
  • Trifocal Lenses
  • Lenticular Lenses
  • Frame
  • Up to $40
  • Up to $40
  • Up to $60
  • Up to $80
  • Up to $125
  • Up to $45
Limitations *When an examination and/or materials are received from a VSP Participating Provider, the patient will have no out-of-pocket expense other than the copayment, unless optional items are selected. Optional items include, but are not limited to, oversize lenses (61 mm or larger), coated lenses, no-line multifocal lenses, treatments for cosmetic reasons or a frame that exceeds the wholesale allowance.

This is an outline only to provide a summary of benefits. It does not constitute the group policy and is not a contract of insurance. This outline provides essential features of the group benefits provided. All rights with respect to the benefits of an insured person will be governed solely by the current group policy.

For specific Plan benefits, limitations or exclusions please call VSP at (800) 877-7195 or visit their website at www.vsp.com.

 

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Last modified: March 3, 2009
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