northeast csd and vsp provide you an affordable • $10.00 ... · $130.00 allowance for contacts...

0723278 - 06/21/11 NORTHEAST CSD and VSP provide you an affordable eyecare plan. Sign up today. Important Dates VSP Coverage Effective...................................... 07/01/2011 Doctor Network..................................... VSP Signature Your Coverage with a VSP Doctor WellVision Exam ® focuses on your eye health and overall wellness • $10.00 copay...................................... every 12 months Prescription Glasses • $25.00 copay Lenses.................................................. every 12 months • Single vision, lined bifocal and lined trifocal lenses • Polycarbonate lenses for dependent children Frame................................................... every 24 months • $130 allowance for a wide selection of frames • 20% off amount over your allowance ~OR~ Contact Lens Care No copay applies.................................. every 12 months $130.00 allowance for contacts and the contact lens exam (fitting and evaluation) Current soft contact lens wearers may qualify for a special program that includes a contact lens exam and initial supply of lenses. Your Contribution Employee Only............................................$12.47 Monthly Employee + One Dependent...................... $19.96 Monthly Employee + Family..................................... $32.85 Monthly Employee + Child(ren)............................... $20.37 Monthly Extra Discounts and Savings Glasses and Sunglasses •Average 35 - 40% savings on all non-covered lens options •30% off additional glasses and sunglasses, including lens options, from the same VSP doctor on the same day as your WellVision Exam. Or get 20% off from any VSP doctor within 12 months of your last WellVision Exam Contacts •15% off cost of contact lens exam (fitting and evaluation) Laser Vision Correction •Average 15% off the regular price or 5% off the promotional price. Discounts only available from contracted facilities. •After surgery, use your frame allowance (if eligible) for sunglasses from any VSP doctor. Your Coverage with Other Providers Visit vsp.com for details, if you plan to see a provider other than a VSP doctor. Exam................................................................ Up to $ 50.00 Single Vision Lenses........................................ Up to $ 50.00 Lined Bifocal Lenses........................................ Up to $ 75.00 Lined Trifocal Lenses..................................... Up to $ 100.00 Frame............................................................... Up to $ 70.00 Contacts......................................................... Up to $ 105.00 VSP guarantees service from VSP doctors only. In the event of a conflict between this information and your organization's contract with VSP, the terms of the contract will prevail.

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Page 1: NORTHEAST CSD and VSP provide you an affordable • $10.00 ... · $130.00 allowance for contacts and the contact lens exam (fitting and evaluation) Current soft contact lens wearers

0723278 - 06/21/11

NORTHEAST CSD and VSP provide you an affordableeyecare plan. Sign up today.

Important DatesVSP Coverage Effective......................................07/01/2011Doctor Network..................................... VSP Signature

Your Coverage with a VSP Doctor

WellVision Exam® focuses on your eye health and overallwellness

• $10.00 copay......................................every 12 months

Prescription Glasses

• $25.00 copay

Lenses..................................................every 12 months• Single vision, lined bifocal and lined trifocal lenses

• Polycarbonate lenses for dependent childrenFrame................................................... every 24 months• $130 allowance for a wide selection of frames

• 20% off amount over your allowance

~OR~

Contact Lens Care

No copay applies..................................every 12 months

$130.00 allowance for contacts and the contact lens exam(fitting and evaluation)

Current soft contact lens wearers may qualify for a specialprogram that includes a contact lens exam and initial supplyof lenses.

Your Contribution

Employee Only............................................$12.47 Monthly

Employee + One Dependent......................$19.96 Monthly

Employee + Family.....................................$32.85 Monthly

Employee + Child(ren)............................... $20.37 Monthly

Extra Discounts and Savings

Glasses and Sunglasses •Average 35 - 40% savings on all non-covered lens options •30% off additional glasses and sunglasses, including lensoptions, from the same VSP doctor on the same day asyour WellVision Exam. Or get 20% off from any VSP doctorwithin 12 months of your last WellVision Exam

Contacts •15% off cost of contact lens exam (fitting and evaluation)

Laser Vision Correction •Average 15% off the regular price or 5% off the promotionalprice. Discounts only available from contracted facilities. •After surgery, use your frame allowance (if eligible) forsunglasses from any VSP doctor.

Your Coverage with Other Providers

Visit vsp.com for details, if you plan to see a provider other than aVSP doctor.

Exam................................................................Up to $ 50.00

Single Vision Lenses........................................Up to $ 50.00

Lined Bifocal Lenses........................................Up to $ 75.00

Lined Trifocal Lenses.....................................Up to $ 100.00

Frame...............................................................Up to $ 70.00

Contacts.........................................................Up to $ 105.00

VSP guarantees service from VSP doctors only. In the eventof a conflict between this information and your organization'scontract with VSP, the terms of the contract will prevail.

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