Vision Plan C

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 12-month period.

Frames - once in each 12-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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