VISION PLAN C

Maximum Annual Benefits	Examination - once in each 12-month period. Lenses - once in each 12-month period. Frames - once in each 12-month period.
Co-payment	Varies from $0 to $15 depending on the Plan chosen by your employer.
Benefits	Services from a VSP Participating Provider*
	Examination Single Vision Lenses Bifocal Lenses Trifocal Lenses Lenticular Lenses Frame Contacts Laser Correction Surgery	Paid in full Paid in full Paid in full Paid in full Paid in full Frame allowance of $130 plus 20% discount on any frame overage cost. Contact allowance of $120 which applies to the contact lens exam (if needed) and materials. Reduced price, discount on preoperative and postoperative care. Save an average 15% off the regular price or 5% off the promotional price, which could add up to hundreds of dollars in savings.
Benefits	Services from a Non-Participating Provider
	Examination Single Vision Lenses Bifocal Lenses Trifocal Lenses Lenticular Lenses Frame	Up to $40 Up to $40 Up to $60 Up to $80 Up to $125 Up to $45
Limitations	*When an examination and/or materials are received from a VSP Participating Provider, the patient will have no out-of-pocket expense other than the copayment, unless optional items are selected. Optional items include, but are not limited to, oversize lenses (61 mm or larger), coated lenses, no-line multifocal lenses, treatments for cosmetic reasons or a frame that exceeds the wholesale allowance.
This is an outline only to provide a summary of benefits. It does not constitute the group policy and is not a contract of insurance. This outline provides essential features of the group benefits provided. All rights with respect to the benefits of an insured person will be governed solely by the current group policy. For specific Plan benefits, limitations or exclusions please call VSP at (800) 877-7195 or visit their website at www.vsp.com.

To view your personal benefit information, register online at VSP.