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Vision Plan Summary

VSP

PROVIDER NETWORK: VSP Choice

Premier Program

Benefit	Description	Co-pay	Frequency
WELLVISION EXAM	Focuses on your eyes and overall wellness	$10	Every Calendar year
ESSENTIAL MEDICAL EYE CARE	Retinal screening for members with diabetes Additional exams and services beyond routine care to treat $20 per exam immediate issues from pink eye to sudden changes in vision or to monitor ongoing conditions such as dry eye, diabetic eye disease, glaucoma, and more. Coordination with your medical coverage may apply. Ask your VSP doctor for details.	$20 per screening $20 per exam $20 Per exam	Available as needed Available as needed Available as needed
PRESCRIPTION GLASSES		$25
FRAME⁺	$170 featured frame brands allowance $150 frame allowance 20% savings on the amount over your allowance $80 Costco® frame allowance	Included in Prescription Glasses	Every other calendar year
LENSES	Single vision, lined bifocal, and lined trifocal lenses Impact-resistant lenses for dependent children	Included in Prescription Glasses	Every calendar year
LENS ENHANCEMENTS	Standard progressive lenses Premium progressive lenses Custom progressive lenses Average savings of 30% on other lens enhancements	$0 $95 - $105 $150 - $175	Every calendar year
CONTACTS (INSTEAD OF GLASSES)	$130 allowance for contacts; copay does not apply Contact lens exam (fitting and evaluation)	Up to $60	Every calendar year
EXTRA SAVINGS	Glasses and Sunglasses Extra $20 to spend on featured frame brands. Go to vsp.com/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.
	Routine 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
YOUR COVERAGE GOES FURTHER IN-NETWORK
With so many in-network choices, VSP makes it easy to get the most out of your benefits. You’ll have access to preferred private practice, retail, and online in-network choices. Log in to vsp.com to find an in-network provider.

+Coverage with a retail chain may be different or not apply.

VSP guarantees member satisfaction from VSP providers only. Coverage information is subject to change. In the event of a conflict between this information and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location. In the state of Washington, VSP Vision Care, Inc., is the legal name of the corporation through which VSP does business. TruHearing is not available directly from VSP in the states of California and Washington.