OPERACIONES VINCULADAS Y OPERACIONES INTRAGRUPO

You may choose any one of the following family categories or you may elect no coverage.

● Employee Only

● Employee Plus Child(ren) ● Employee Plus One Adult

● Employee Plus One Adult Plus Child(ren) Your Family Category for VSP may be different from your Medical and Dental categories.

VSP Member Provider Affiliate Provider Non-member Provider

Eye Exam 100% after $15 copay once every 12 months

100% after $15 copay once every 12 months

Up to $50 once every 12 months after $15 copay

Prescription Glasses

● Lenses

●Single vision, lined, bifocal and lined trifocal lenses, lenticular lenses, or ●Progressive,

photochromic, tints, ultraviolet coating, scratch coating, and antireflective coating, or

●Polycarbonate lenses for dependent children

● Frame of your choice

● 100% once every 12 months

● 100% once every 24 months up to $120 plus 20% discount on any out-of-pocket costs

● 100% once every 12 months

● 100% once every 24 months up to $120 plus 20% discount on any out-of-pocket costs

● Up to $40 for single vision, or ● Up to $60 for lined bifocal, or ● Up to $80 for lined trifocal, or ● Up to $125 for lenticular, and ● Up to $5 for tinting (total) Once up to every 12 months ● Up to $45 once every 24 months

OR

● Contact Lens Care ●includes cost of your

contacts and the contact lens fitting and evaluation (in addition to vision exam)

● 100% once every 12 months up to $200 allowance for elective contact lenses

● Visually necessary contact lenses at 100% with pre-authorization, once every 12 months

● 100% once every 12 months up to $200 allowance for elective contact lenses

● Up to $210 for visually necessary contact lenses at 100%, once every 12 months

● Up to $200 once every 12 months for elective contact lenses ● Up to $210 for visually

necessary contact lenses with pre-authorization, once every 12 months

Extra Discounts and Savings Using a VSP Network Provider Glasses and Sunglasses

● Average 35 - 40% savings on all non-covered lens options ● 30% off additional glasses and sunglasses, including lens options, from the same VSP doctor on the same day as your WellVision Exam. Or get 20% off from any VSP doctor within 12 months of your last WellVision Exam

Contacts

● 15% off cost of contact lens exam (fitting and evaluation)

Laser Vision Correction

Costco

● Costco pricing applies; there are no additional discounts

All Other Affiliate Provider Locations

● 20% off additional glasses and 15% off contact lens services within one year

eyeglasses, and/or prescription contact lenses. You can go to any provider you wish, but you’ll receive a higher level of benefits if you choose a doctor who participates in the VSP network.

When you use a VSP doctor, most services are covered in full after the copay and you will also receive discounts and preferred member pricing. Best of all, there are no claim forms to file. Simply make an appointment with a participating VSP doctor and identify yourself as a VSP member. To determine if your doctor is part of VSP’s network, or to find a new vision care provider, contact VSP Customer Service at 1-800-877-7195 or visit VSP’s website www.vsp.com .

At the time of your appointment, you pay the copay (if any) to the Member Doctor for covered services, plus any charges in excess of the plan benefits. The Member Doctor will handle the paperwork for receiving payment of the VSP benefits.

Affiliate providers are providers of covered services and materials who are not contracted as Member Doctors but who have agreed to bill VSP directly for covered services and to receive the scheduled benefit. Some affiliate providers may not be able to provide all the services included in this plan; please discuss requested services with your provider or contact VSP Customer Service.

If you are enrolled and obtain vision services from a Non-member Doctor, you pay the full cost of care. You will need to submit a claim to VSP within one year of the date of service to receive reimbursement as shown on the schedule on the previous page. Visit www.vsp.com for forms. The scheduled benefit is only available once per 12 or 24 month period, depending on service, whether provided by Member Doctor, Affiliate Provider or Non-member Doctor.

visual problems that cannot be corrected with regular lenses, you may be eligible for additional benefits. The VSP doctor will determine if a patient meets the benefit criteria for low vision benefits at the time of service. If the patient does the VSP doctor will submit a verification form and obtains a Benefit Authorization Notice from VSP .

Complete low vision analysis/diagnosis includes a comprehensive exam and subsequent low vision aids as Visually Necessary or Appropriate.

What is Covered VSP Provider Affiliate and Non-member Provider Supplemental Testing ● 100% ● Up to $125 Supplemental Care Aids ● 75% ● 75%

Benefit Maximum $1,000 every two years

Maximum of two supplemental tests in a two year period

Vision Expenses Not Covered or

Limited Benefits

The VSP plan is designed to cover visual needs rather than cosmetic materials. If you choose any of the following extras, the plan will pay the basic cost of the allowed lenses, and you pay the additional cost for the options. Discounts may be available. See the previous schedule.

● optional cosmetic processes ● color coating ● mirror coating ● cosmetic lenses ● laminated lenses ● polycarbonate lenses ● oversize lenses

● certain limitations on low vision care ● a frame that costs more than the Plan

No benefits will be payable for the following: ● care, treatment or supplies received prior to or

after coverage under this Plan

● orthoptics or vision training and any associated supplemental testing

● plano lenses (less than ±.50 diopter power) ● two pair of glasses in lieu of bifocals

● replacement of lenses and frames furnished under this Plan which are lost or broken, except at the normal intervals when services otherwise available

● medical or surgical treatment of the eyes ● corrective vision of an experimental nature ● costs for services and/or materials above Plan

Benefit allowances

● services and/or materials not indicated as covered Plan benefits in the schedule shown on page 4-1