DeluxePlan

Resources
» Find a VSP Signature Network Vision Doctor
» Plan Contracting Kit
» Plan Brochure
» Glosary of Terms
» Member Enrollment Form
» Member Flyer - Provider Network
» Member Flyer - Get the Most of Your Benefit
» Member Flyer - See Well Stay Health
» Out-of-Network Reimbursement Form


Coverage Details
WellVision Exam
Once every 12-months receive a WellVision Exam for a $10 Co-Pay.

Materials Deductible
Once every 12-months pay a $25 Deductible for Lenses and/or Frames.

Lenses
Once every 12-months receive Single, Lined-Bifocal, Lined-Trifocal or Standard Progressive (No-Line) Lenses for Free after the Materials Deductible, if not already met. Or, receive Premium Progressive Lenses for an $80-$90 Co-Pay, or Custom Progressive Lenses for a $120-$160 Co-Pay after the Materials Deductible, if not already met.

Lens Customizations
Tints, Dyes, Photochromics & Polycarbonate Lenses are Free. Scratch-Resistance Coatings, High Index Lenses, Edge Polishing, UV Protective Coatings, Anti-Reflective Coatings and other Lens Customizations are Discounted.

Frames
Once every 12-months spend up to $130 and receive a 20% Discount for amounts over that, after the Materials Deductible, if not already met. For additional glasses or sunglasses receive a 20% Discount.

Contact Lenses
Instead of Lenses and/or Frames, once every 12-months spend up to $125 on Contact Lenses. Additionally, once every 12-months receive a 15% Discount on a Contact Lens Fitting & Evaluation, paying a maximum of $60, without reducing the amount available for Contact Lenses.

ValueAdd Programs
Laser Vision Correction is Discounted. Diabetic EyeCare Plus provides follow-up medical care for Members with Type I or II Diabetes. TruHearing offers 20% Discount for Digitial Hearing Aids. Visit www.vsp.com for more details on all 3 programs.

Out-of-Network Coverage
Out-of-Network Reimbursement Form
Members can utilize out-of-network providers, but they will be required to pay the provider in full at the time of service. Members can then apply for a partial reimbursement directly from VSP. Claims must be filed within 6-months of the date of service. Members may receive the following reimbursement allowances for out-of-network services after any applicable co-pays or deductibles:

$  50  Exam
$  50  Single Vision Lenses
$  75  Lined Bifocial Lenses
$100  Lined Trifocal Lenses
$125  Lenticular Lenses
$  75  Progressive Lenses
$  70  Frames
$105  Elective Contact Lenses
$    5  Tints



Monthly Rates
Use Employer Sponsored rates when employees pay less than 50% of the premium
Use Voluntary (Employee Paid) rates when employees pay more than 50% of the premium


DeluxePlan
       Employer            Voluntary
Sponsored (Employee Paid)
Member 12.48 14.48
Member & Spouse 21.74 22.24
Member & Child(ren) 22.74 22.74
Family 38.24 35.48


DeluxePlan
with Comprehensive Progressive Lens Coverage
       Employer            Voluntary
Sponsored (Employee Paid)
Member 13.48 15.98
Member & Spouse 23.74 24.74
Member & Child(ren) 24.74 24.74
Family 42.24 39.74


DeluxePlan
with Computer VisionCare Coverage
       Employer            Voluntary
Sponsored (Employee Paid)
Member 14.48 16.98
Member & Spouse 23.74 24.24
Member & Child(ren) 24.74 24.74
Family 40.24 37.98


DeluxePlan
with Comprehensive Progressive Lens & Computer VisionCare Coverage
       Employer            Voluntary
Sponsored (Employee Paid)
Member 15.48 18.48
Member & Spouse 26.24 26.74
Member & Child(ren) 26.74 27.24
Family 43.74 42.24