Summary Plan Description

Vision Benefits

Vision benefits are available to you and your dependents based on the network and non-network schedules below.

Network Benefits – VSP Vision Care
Benefit Description Copay Frequency
WellVision Exam
  • Focuses on your eyes and overall wellness
$0 for exam and glasses Every calendar year
Prescription Glasses $0  
 

Frame

  • $150 allowance for a wide selection of frames
  • $170 allowance for featured frame brands
  • 20% savings on the amount over your allowance
  • $80 Costco frame allowance
  Every calendar year
 

Lenses

  • Single vision, lined bifocal, and lined trifocal lenses
  • Polycarbonate lenses for dependent children
  Every calendar year
Lens Enhancements
  • Anti-reflective coating
  • Scratch coating
  • Progressive lenses
  • Average savings of 20-25% on other lens enhancements
$0
$0
$55 – $175
Every calendar year
Contacts (instead of glasses)
  • $150 allowance for contacts; copay does not apply
  • Contact lens exam (fitting and evaluation)
Up to $60 Every calendar year
Diabetic Eyecare Plus Program
  • Services related to diabetic eye disease, glaucoma and age-related macular degeneration (AMD). Retinal screening for eligible patients with diabetes. Limitations and coordination with medical coverage may apply. Ask your VSP doctor for details
$20 As needed
Extra Savings Glasses and Sunglasses
  • Extra $20 to spend on featured frame brands. Go towww.vsp.com/optical-discounts.html offers for details.
  • 20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12 months of your last WellVision Exam
Retinal Screening
  • No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam
Laser Vision Correction
  • Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities
Non-Network Benefits
Benefit Description Copay Frequency
Exam
  • Focuses on your eyes and overall wellness
Up to $100 Every calendar year
Frame   Up to $90 Every calendar year
Lenses
  • Single vision lenses
  • Lined bifocal lenses
  • Lined trifocal lenses
Up to $75
Up to $105
Up to $150
Every calendar year
Lens Enhancements
  • Progressive lenses
Up to $105 Every calendar year
Contacts (instead of glasses)   Up to $125 Every calendar year