How the Plans Pay Benefits


	Basic Vision		Buy-up Vision
Benefits	VSP Preferred Provider	Non-VSP Provider Reimbursement	VSP Preferred Provider	Non-VSP Provider Reimbursement
Exam	Covered in full after a $25 copayment	Covered up to $45 after a $25 copayment	Covered in full	Covered up to $70
Lenses
Single vision	Standard lenses paid in full after $25 copayment	Covered up to $45 after $25 copayment	Standard lenses covered in full	Covered up to $50
Lined bifocal	Standard lenses paid in full after $25 copayment	Covered up to $65 after $25 copayment	Standard lenses covered in full	Covered up to $75
Lined trifocal	Standard lenses paid in full after $25 copayment	Covered up to $85 after $25 copayment	Standard lenses covered in full	Covered up to $100
Polycarbonate lenses (for dependent children)	Covered in full	Not covered	Covered in full	Not covered
Progressive	35% – 40% discount off usual and customary charges	Covered up to $85 after $25 copayment	35% – 40% discount off usual and customary charges	Covered up to $100
Frame	Covered up to $120, 20% off remaining balance	Covered up to $47	Covered up to $100, 20% off remaining costs	Covered up to $75
Contacts in lieu of lenses and a frame	Covered up to $105	Covered up to $105 for contact lens exam and contacts	Covered up to $137	Covered up to $137 for contact lens exam and contacts
Contact Lens Exam (fitting and evaluation)	Covered in full after a not-to-exceed copay of $60		Covered in full after a not-to-exceed copay of $60
Benefit Frequency
Exam	Once every 24 months for children and adults		Once every 12 months for children up to age 17; every 24 months for adults
Lenses	Once every 24 months for children and adults		Once every 12 months for children up to age 17; every 24 months for adults
Frames	Once every 24 months for children and adults		Once every 24 months for children and adults