TraditionalPlan

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 $15 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
Polycarbonate Lenses for Kids are Free. Tints, Dyes, Photochromic & Polycarbonate Lenses for Adults are Discounted. Scratch-Resistance, Anti-Reflective Coatings and other Lens Customizations are Discounted.

Frames
Once every 12-months spend up to $110 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 $120 on Contact Lenses. Additionally, once every 12-months receive a 15% Discount on a Contact Lens Fitting & Evaluation, without reducing the amount available for Contact Lenses. Note: Purchase of Contact Lenses resets the 24-month Frames waiting period.

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


TraditionalPlan
       Employer            Voluntary
Sponsored (Employee Paid)
Member   7.74 9.74
Member & Spouse 13.48 14.98
Member & Child(ren) 13.98 14.98
Family 23.74 23.74


TraditionalPlan
with Comprehensive Progressive Lens Coverage
       Employer            Voluntary
Sponsored (Employee Paid)
Member   8.74 10.74
Member & Spouse 14.98 16.48
Member & Child(ren) 15.48 16.98
Family 26.48 26.74


TraditionalPlan
with Computer VisionCare Coverage
       Employer            Voluntary
Sponsored (Employee Paid)
Member 9.74 11.98
Member & Spouse 15.48 16.98
Member & Child(ren) 15.98 17.48
Family 25.74 26.24


TraditionalPlan
with Comprehensive Progressive Lens & Computer VisionCare Coverage
       Employer            Voluntary
Sponsored (Employee Paid)
Member 11.24 13.48
Member & Spouse 17.98 18.98
Member & Child(ren) 18.48 19.48
Family 30.24 30.24