VISION PLAN
SUMMARY OF COVERAGE
VSP
Benefits
In-Network
Out-of-Network
Frequency
Exam
Covered 100%
Up to $50
Every 12 Months
Lenses - Single Vision
Single Vision – Up to $48 Bifocal – Up to $67 Trifocal – Up to $86
$25 Copay
Every 12 Months
- Bifocal - Trifocal
Covered at 80% up to $200
Frames
Up to $48
Every 12 Months
Contacts (Medically Necessary) Contacts (Elective) (In lieu of lenses)
Coveredat 100%
Up to $210
Every 12 Months
$135 Allowance
Up to $130
Every 12 Months
• Note: If you enroll your domestic partner or domestic partner’s child(ren), you will be taxed on imputed income.
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VISION PLAN I
SENDOSO BENEFITS GUIDE
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