Vision Service Plan (VSP)

January 1, 2004 - January 1, 2005

Information provided is in summary format.  Any difference between the summary provided and actual contract will be settled in favor of the contract.

In-Network

Out-Of-Network

Vision Network:

VSP Participating Providers

Non-Participating Providers

$25 for materials only

Vision Exam:

     Time Limit

One every 12 months

     Payment Limit

Paid at 100%

Up to $40 reimbursement

Frames:

     Time Limit

One pair every 24 months

     Payment Limit

100% of allowed amount

Up to $45 reimbursement

Necessary Contact Lenses:

     Time Limit

One pair of either contacts or lenses every 12 months

     Payment Limit

100%

$210

Elective Contact Lenses:

     Time Limit

One pair of either contacts or lenses every 12 months

     Payment Limit

$105

$105