USAvision - Premier Vision Plan

PremierPlan

On this Page
» Resources
» In-Network Coverage
» Computer VisionCare Enhancement
» Progressive Lenses Enhancement
» Out-of-Network Coverage
» Monthly Rates

Resources

In-Network Coverage


WellVision Eye Exam
» Frequency		12 Months
» Exam		Free
» Digital Retinal Scan		$39 Co-Pay

Materials
» Frequency		12 Months
» Deductible		Free

Lenses
» Frequency		12 Months
» Single Vision		Free
» Lined Bifocal		Free
» Lined Trifocal		Free
» Standard Progressives		Free
» Premium Progressives		$95-$105 Co-Pay - Choice Network
		$80-$90 Co-Pay - Signature Network
» Custom Progressives		$150-$175 Co-Pay - Choice Network
		$120-$160 Co-Pay - Signature Network
» High Index		30% Average Discount - Choice Network
		40% Average Discount - Signature Network
» Polarized		30% Average Discount - Choice Network
		40% Average Discount - Signature Network
» Impact-Resistant		30% Average Discount - Choice Network
		40% Average Discount - Signature Network

Lens Customizations
» Polycarbonates for Children		Free
» Polycarbonates for Adults		Free
» Transitional (Photochromic)		Free
» Tinting		Free
» Scratch-Resistant		30% Average Discount - Choice Network
		40% Average Discount - Signature Network
» Anti-Reflective Coatings		30% Average Discount - Choice Network
		40% Average Discount - Signature Network
» UV Coatings		30% Average Discount - Choice Network
		40% Average Discount - Signature Network
» Other Lens Customizations		30% Average Discount - Choice Network
		40% Average Discount - Signature Network

Frames
» Frequency		12 Months
» Coverage		$170 Allowance
» Featured Brand Coverage		$190 Allowance
» Coverage After Allowance		20% Discount

Extra Savings
» Additional Glasses		20% Discount
» Additional Sunglasses		20% Discount
» Blue-Light Filtering Glasses		20% Discount

Contact Lenses
(Instead of Lenses and/or Frames)
» Frequency		12 Months
» Coverage		$150 Allowance
» Fitting & Evaluation Exam		Max $60 Co-Pay
» Medically Necessary Contacts		Free

Laser Vision Surgery
» Coverage		Discounted

Essential Medical Eye Care Services
» Coverage		$20 Co-Pay
» Services		Retinal Screening for Diabetics
		Medical Exams & Services for diagnosis, treatment, & management of chronic conditions, such as diabetic eye disease, glaucoma, & age-related macular degeneration.
		Treatment for Urgent Conditions such as eye infections, foreign body & abrasions, eye injuries, & eye or eyelid chemical exposure.
		Medical Tests for diagnosis & treatment of sudden vision changes, such as eye flashes, floaters, & sudden vision loss.
		Other Vision Medical Services

Hearing
» Frequency		12 Months
» Digital Hearing Aids		Up to 60% Discount
» Online Hearing Test		Free
» Hearing Aid Batteries		120 for $39

Computer VisionCare Enhancement

The optional Computer VisionCare enhancement provides additional computer vision specific coverage for the Employee Only. After an employee completes a simple questionnaire, and pays a $25 Co-Pay, they will receive a supplemental, limited eye exam to determine their specific visual needs for computer use. After this eye exam, if it is prescribed, employees will receive an additional pair of glasses to meet their computer use needs for Free.

Progressive Lenses Enhancement

This optional enhancement can be added to any base plan for a small additional cost. It makes Premium & Custom Progressive Lenses available at the Materials Deductible, instead of the more expensive Co-Pays under the base plan design.

Out-of-Network Coverage

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 using the Out-of-Network Reimbursement Form. Claims must be filed within 6 Months of the date of service. Members may receive up to the following reimbursement allowances for out-of-network services after any applicable co-pays or deductibles:


	ChoiceNetwork	SignatureNetwork

» Exam	45	50
» Frames	70	70
» Single Vision Lenses	30	50
» Bifocal Lenses (Lined or No-Line)	50	75
» Trifocal Lenses (Lined or No-Line)	65	100
» Progressive Lenses	50	75
» Lenticular Lenses	100	125
» Elective Contacts	105	105
» Medically Necessary Contacts	210	210

Monthly Rates

Employer Sponsored Rates are for when employees pay less than 50% of the premium.
Voluntary (Employee Paid) Rates are for when employees pay more than 50% of the premium.

PremierPlan

	ChoiceNetwork		SignatureNetwork
	Employer	Voluntary	Employer	Voluntary
	Sponsored	(Employee Paid)	Sponsored	(Employee Paid)
Member	16.24	19.48	17.98	21.74
Spouse & Member	24.24	28.74	27.24	32.48
Child(ren) & Member	24.74	29.24	27.74	32.98
Family	39.24	45.98	44.24	51.98

PremierPlan
with Progressive Lenses Enhancement

	ChoiceNetwork		SignatureNetwork
	Employer	Voluntary	Employer	Voluntary
	Sponsored	(Employee Paid)	Sponsored	(Employee Paid)
Member	17.98	21.24	20.24	23.74
Spouse & Member	27.24	32.24	30.48	35.98
Child(ren) & Member	27.74	32.24	30.98	35.48
Family	43.98	52.24	48.98	58.24

PremierPlan
with Computer VisionCare Enhancement

	ChoiceNetwork		SignatureNetwork
	Employer	Voluntary	Employer	Voluntary
	Sponsored	(Employee Paid)	Sponsored	(Employee Paid)
Member	17.98	20.74	20.24	23.74
Spouse & Member	26.24	30.48	29.48	33.98
Child(ren) & Member	26.48	30.98	29.98	34.98
Family	40.98	47.98	45.74	53.48

PremierPlan
with Computer VisionCare & Progressive Lenses Enhancements

	ChoiceNetwork		SignatureNetwork
	Employer	Voluntary	Employer	Voluntary
	Sponsored	(Employee Paid)	Sponsored	(Employee Paid)
Member	19.48	22.98	21.74	25.48
Spouse & Member	28.48	33.24	31.98	37.24
Child(ren) & Member	28.98	33.48	32.48	37.48
Family	44.98	53.24	50.48	59.74