Vision
Healthy eyes and clear vision are an important part of your overall health and quality of life. You may enroll yourself and your eligible dependents or you may waive vision coverage. You do not have to be enrolled in medical coverage to elect vision coverage or cover the same dependents under medical and vision.
Although vision care services and supplies are covered in-network and out-of-network, your benefits are generally greater when you use in-network providers. Your costs are based on the family members you choose to cover.
VSP Signature PPO
Plan Information
Plan Name: VSP Signature PPO
Policy Number: 12199326
Effective Date: 01/01/2025
Provider Network: VSP
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Exams
$10 copay
Materials
$25 copay
Single Vision Lenses
No charge after materials copay
Bifocal Lenses
No charge after materials copay
Trifocal Lenses
No charge after materials copay
Frames
Covered up to $200 + 20% discount off amount over allowance
Contacts (elective)
Covered up to $150
Frequency
Exams
Once every 12 months
Lenses
Once every 12 months
Frames
Once every 24 months
Contacts (elective)
Once every 12 months (in lieu of lenses and frames)
Additional Benefit
This employee-only service provides supplemental vision analysis addressing the specific visual needs of computer use. The analysis is available once every 12 months.
Exam and Materials
$10 copay
Frames
Covered up to $90
Out-of-Network Reimbursement
Exams
$10 copay (reimbursed up to $50)
Materials
$25 copay
Single Vision Lenses
Reimbursed up to $50 after materials copay
Bifocal Lenses
Reimbursed up to $75 after materials copay
Trifocal Lenses
Reimbursed up to $100 after materials copay
Frames
Reimbursed up to $70 after materials copay
Contacts (elective)
Reimbursed up to $105
Frequency
Exams
Once every 12 months
Lenses
Once every 12 months
Frames
Once every 24 months
Contacts (elective)
Once every 12 months (in lieu of lenses and frames)
Additional Benefit
This employee-only service provides supplemental vision analysis addressing the specific visual needs of computer use. The analysis is available once every 12 months.
Exam and Materials
$10 copay
Frames
Reimbursed up to $70 after materials copay