|
Plan name: |
VSP Vision |
|
Plan year: |
2022 |
|
Group number: |
00108058 |
|
Carrier: |
Vision Service Plan (VSP) |
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.
|
VSP Vision Copay |
In-Network |
Out-Of-Network
|
|
Examination |
$10 copay |
Reimbursed up to $50 after $10 copay |
|
Materials |
$20 copay |
$20 copay (Reimbursed up to plan allowance) |
|
Benefit Frequency |
|
|
|
Examination |
Once every 12 months |
Once every 12 months |
|
Lenses |
Once every 12 months |
Once every 12 months |
|
Frames |
Once every 24 months |
Once every 24 months |
|
Contacts |
Once every 12 months in lieu of frames & lenses |
Once every 12 months in lieu of frames & lenses |
Covered Services
Lenses
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.
|
Employee Rates (monthly) |
Rate |
|
Employee Only |
$2.00 |
|
Employee + 1 |
$4.00 |
|
Employee + Child(ren) |
$4.00 |
|
Family |
$4.00 |
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.
|
Title/Department: |
VSP Member Services |
|
Phone: |
800-877-7195 |
|
URL: |
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.