Vision Coverage

As low as $9.82
SKU
Vision Coverage

Member Information

Social Security Number (required for insurance products)

Spouse Information

First Name Last Name Date of Birth
Gender Social Security Number


Child Information

First Name Last Name Date of Birth
Gender Social Security Number

MONTHLY VSP VISION
Employee Only $9.82
Employee + Spouse $17.96
Employee + Child(ren) $17.02
Family $29.12

 

BENEFITS

Network/Plan VSP Vision
Copay (Exams/Materials) $10/$25

 

SERVICE FREQUENCIES

Eye Exams Once Every 12 months
Lenses Benefit Once Every 12 months
Contact Lenses Once Every 12 months
Frames Once Every 24 months

 

REIMBURSEMENT SCHEDULE

  In-Network
(Copay)
Out-of-Network
(Before Copay)
Eye Exams $10 $50 max

Lenses Benefit

Single Vision
Bifocal
Trifocal
Lenticular

 

$25
$25
$25
$25

 

$48 max
$67 max
$86 max
$126 max

Contact Lenses Benefit

Medically Necessary
Elective Materials

 

Covered (Copay Waived)
$150 max + 15% off

 


$210 max
$105 max

Frames Benefit

$150 retail max + 20% off

$48 max

 

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