YOUR VSP VISION BENEFITS SUMMARY Coverage with a VSP Provider—Basic Plan Coverage with a VSP Provider—Premier Plan Beneft Description Copay Beneft Description Copay WellVision • Focuses on your eyes and overall wellness $10 WellVision • Focuses on your eyes and overall wellness $10 Exam • Routine retinal imaging Up to $39 Exam • Routine retinal imaging Up to $39 • Every calendar year • Every calendar year • Retinal imaging for members with diabetes • Retinal imaging for members with diabetes covered-in-full. covered-in-full. • Additional exams and services beyond routine care $20 • Additional exams and services beyond routine care $20 Essential to treat immediate issues from pink eye to sudden per exam Essential to treat immediate issues from pink eye to sudden per exam Medical Eye changes in vision or to monitor ongoing conditions Medical Eye changes in vision or to monitor ongoing conditions Care such as dry eye, diabetic eye disease, glaucoma Care such as dry eye, diabetic eye disease, glaucoma and more. and more. • Coordination with your medical coverage may apply. • Coordination with your medical coverage may apply. Ask your VSP network doctor for details. Ask your VSP network doctor for details. • Available as needed • Available as needed Prescription Glasses Prescription Glasses • $110 allowance for a wide selection of frames • $210 allowance for a wide selection of frames • $130 allowance for featured frame brands • $230 allowance for featured frame brands Frame • 20% savings on the amount over your allowance Frame* • 20% savings on the amount over your allowance • Every other calendar year • $115 Walmart/Sam’s Club/Costco frame allowance $0 • Every calendar year $0 • Single vision, lined bifocal, and lined trifocal lenses • Single vision, lined bifocal, and lined trifocal lenses Lenses • Impact-resistant lenses for dependent children Lenses • Impact-resistant lenses for dependent children † • Every other calendar year • Every calendar year • UV protection $0 • UV protection $0 • Standard progressive lenses $55 • Tinted lenses $0 Lens • Premium progressive lenses $95-$105 Lens • Standard progressive lenses $0 Enhancements • Custom progressive lenses $150-$175 Enhancements • Premium progressive lenses $95-$105 • Average savings of 20–25% on other lens • Custom progressive lenses $150-$175 enhancements • Average savings of 30% on other lens enhancements • Every other calendar year • Every calendar year Contacts • $120 allowance for contacts and contact lens exam Contacts • $200 allowance for contacts and contact lens exam (ftting and evaluation) (ftting and evaluation) • 15% savings on a contact lens exam • 15% savings on a contact lens exam (instead of $0 (instead of $0 glasses) (ftting and evaluation) glasses) (ftting and evaluation) † • Every calendar year • Every other calendar year • $110 allowance for ready-made non-prescription • $210 allowance for ready-made non-prescription VSP sunglasses, or ready-made non-prescription blue VSP sunglasses, or ready-made non-prescription blue light fltering glasses, instead of prescription glasses $0 TM TM light fltering glasses, instead of prescription glasses $0 Lightcare * or contacts. Lightcare * or contacts. • Every other calendar year • Every calendar year VSP Computer • Evaluates your vision needs related to computer use Vision Care • $95 allowance for a wide selection of frames (Employee-only • Single vision, lined bifocal, lined trifocal and occupational lenses $10 † coverage) • Every other calendar year Glasses and Sunglasses • Discover all current eyewear offers and savings at vsp.com/offers • 20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12 months of your WellVision Exam. Additional Exclusive Member Extras Savings • Save up to 60% on digital hearing aids with TruHearing. Visit vsp.com/offers/special-offers/hearing-aids for details. • Contact lens rebates, lens satisfaction guarantees, and more offers at vsp.com/offers. • Everyday savings on entertainment, health and wellness, travel and more with VSP Simple Values. Laser Vision Correction • Average of 15% off the regular price; discounts available at contracted facilities. †Only available to VSP members with applicable plan benefts. Frame brands and promotions are subject to change. ‡Savings based on doctor’s retail price and vary by plan and purchase selection; average savings determined after benefts are applied. Ask your VSP network doctor for more details. *Coverage with a retail chain may be different or not apply. †New lenses will be approved every calendar year if the new prescription differs from the original by at least .50 diopter sphere or cylinder, there’s a change in the axis of 15 degrees or more, or a difference in vertical prism greater than one prism. VSP guarantees member satisfaction from VSP providers only. Coverage information is subject to change. In the event of a confict between this information and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefts may vary by location. In the state of Washington, VSP Vision Care, Inc., is the legal name of the corporation through which VSP does business. TruHearing is not available directly from VSP in the states of California and Washington. To learn about your privacy rights and how your protected health information may be used, see the VSP Notice of Privacy Practices on vsp.com. ©2023 Vision Service Plan. All rights reserved. VSP, Eyeconic, and WellVision Exam are registered trademarks, and VSP LightCare and VSP Premier Edge are trademarks of Vision Service Plan. Flexon and Dragon are registered trademarks of Marchon Eyewear, Inc. All other brands or marks are the property of their respective owners. 104702 VCCM 12