Vision Plan A

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 our web site at www.vsp.com.

Maximum Annual Benefits Examination - once in each 12-month period.
Lenses - once in each 24-month period.

Frames - once in each 24-month period.

Copayment Varies from $-0- to $15 depending on the Plan chosen by your employer.

Benefits Services from a VSP Participating Provider*

Examination Paid in full

Single Vision Lenses Paid in full

Bifocal Lenses Paid in full

Trifocal Lenses Paid in full

Lenticular Lenses Paid in full

Frame Frame coverage is based on wholesale allowance of $50

Contacts For details call VSP at (800) 877-7195

Benefits Services from a Non-Participating Provider

Examination Up to $40

Single Vision Lenses Up to $40

Bifocal Lenses Up to $60

Trifocal Lenses Up to $80

Lenticular Lenses Up to $125

Frame 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.

Phone: (530) 822-5299 or Toll-Free (866) 822-5299

Last modified: 05-30-08

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