‘VISION BENEFITS: IEYou choose ovis a VSP network Provider, ther is copay amount payable by You tothe VSP network Provider a the time ofthe exam and a Separale copay when ames and lenses are ordered NOTE: The copays do not apply tothe exammaterials for contact lenses. Vision Benefits 1 2 Exam: You are problams o tho a ence of vision wettare. the accuracy hed Ionses. Poaroonate lenses fr chien are hon dipensed by 3 USP network Provider. The Plan covers nes once every 2 lowance of up to $190, The frame benef provides You the choice You wil save 20% on Your aut-o-pckel coe. Have Your Doctor help You choase the best frame for You, based on Your VSP coverage. The Plan covers frames anco every 24 Months. For ration on how Yo. for ramos may be alecod You rovoWve coract lonses, pase “Contact Lanees™ Contact Lenses: Eloctve conlact loses are covered up to $130. The contact lans exam (iting land evaluation) is @ separate exam for ensuting proper fk of Your contac and evaluating Your ‘ison withthe contact The Plan covers contact ls exam (fing and evaluation) nfl ater $60 copay. Contact loses are in Tou ofall ther benefs (exam, Ibnses an frames) for that iy prod. Copays donot apply. NOTE: tf You get contact fanather 24 months, You "You get contact lena in Janvary 2073 the again would be January 2045, Medically Necessary contact lenses may Necessary co Provider sched Tenses through a nan-VSP Proviser, You wil ba reimbursed according fo & (ese PROVISIONS FOR A NON-VSP PROVIDER Section, Discounted Contact Lans Services: The addtional Je of VSP fs alo extended to ncide a “The dscount does not apy tothe "Your fing+ Average 35.40% savings on lors options, such as scratch resistance, antec coatings and Progressives. 20% off acional glasses and inal Screening: Guarantees in nework member pricing of $39. 98 an enhancement lo Your "takes @ picture of he back of Your eye, helps Your fou have sovere visual he folowing facts to propose a treatment plan, The wine copay by You jpplemontarytostng pad b. Copay Alter supplomontary testing, the Doctor submits tho treatment plan to VSP consultants forreviow. If the plan approved. VSP wil authorize benef, on a copay basis, wih 75% of ‘ha cost being paid by VSP and 25% of the cost boing pad by You Low vision benefits secures from a non-VSP Pro tho same time lets and copay ‘arangements as desorbed herein fora VSP network Provider. You shoule pay Use her frame allowance to Buy nonprescription sunglasas rom thee VSP Provider. VSP Network Provider and Non-VSP Provider Copay Schedule ere shall be a copay forte exam, payable by You, to Ue VSP network Provider atthe time ofthe exam; rowover matras(eneos anlar rams) ae provicod, You must pay an aabonal copay ato mo ho rasa ace ordored a noted below Bam $10 Lenses andlor ames | $25‘Any acciional care, senice andlor mater, nat covered by thie Pan, may be arranged between You and the Doctor, cve contac ans evaliatontexam and material “The copays wilnot apply towar Provisions for a VSP Network Doctor services may bo secured rom any optometrist, o Indemnity Pan eimoursing according to a sched ‘Sfallonances. You should pay im for Non-VSP Provider Services rom anon-VSP Proviso: Following these stps to flea claim if Yau obtain services andlor mat +. Pay he Provider the fll amount of the bil and request an temized copy ofthe bil hat shows the amount of the eye exam, lens type and frame. ‘+ Member's name and maing aderss: + Member + Member's Employer or group name; and “+ Patents name, elatonsipto member, and date of bth D number, twolve montis of completion of services he schedule Claims must be submited i below. There no assurance th (Out-OF Network Reimbursement Schedul Maximum Reimbursement for services from an Qut-Ot Network Provider PROFESSIONAL FEES Exam coveredupto | $ 50550 $75 $00 $70 (CONTACT LENSES” Necessary $210 Elective $105; + under the nom VSP Provide: rimoursement NOTE: The amounts shown are maximums, The acua shown in te "Maximum Reimbursement for Sercos fom a NomVSP Provide ‘charged bythe Provdor of such sorvices, whichovor isthe east amount, Exclusions and Limitations of Vision Benefits ‘ada Member Door o by calling VSP's Customer Care Division i PATIENT OPTIONS selects any af th Aoteretective coating coor eat Minor coating. Seratch coating, Blended lenses. Cosmete tnses. Laminated lenses Oversize lenses Polycarbonate lnsos. Photochromic lenses, ned lenses except Pink #1 and Pink #2.+ Conta + Atrame: + Cont lenses (except as noted elsewhere he NoT covERED ‘There is no bene or professional services or mate ‘+ Othopies or vision tan Cost fr + Comrctve vision veatmant ofan - vices andr materials above Plan Benet allowances ‘Serves andor materials not ndicated on this Schedule as covered Plan Benet Procedure for Using the Plan 41. Whon You ar ready lo obtain vision care sonices, Tecate a VSP network Doctor, call VSP. VSP notwork Doctor. You noed to 2. When making an appoints fo need te covered member ‘any non-covered charges and nave You sign @ form to pay the VSP network Dactor dracty fr cover have dual coverage and are covered by more tan one vision plan (wr 1 VSP plan, You may be another eater oF Use each plan invialy (based on what each pan offer ‘tom each stat onses fom ane plan lasses (ne ‘iter to separate exams andlor materials glasses from be other plan or Wo sets of1 options andor NOTE: Check wih Your VSP Doctor for coordination of baneft deta, Deter Primary and Secondary Plan “+The pan that covers You as an Empl +The pan that covers You a a Dependent th covered person for whom a chim for bene was denied ‘ember estfeaton numberof the VSP entallee, Your name, reasons You Rancne Cordova, CA 95070-7085 Phone: 1-800-877-7105 ‘Complaints and Grievances TrYou have @ complaint or grievance regarcing VSP service o claim payment, You may communicate Your ‘complaint ¢ gfievance to VSP by usng @ complaint form, whien may be obtained by caling the VSP Member Senices Departments tollree number at 1-800-877-7185 Monday through ray, § 00 AM 7:00, ‘0 AM ~ 230 be sont ta the adress ‘tlovanc process before contacting Pe Heath Plan OvisionIF You need help with a grievance invling an emergency, a grievance that has rot been saisfacorly solved bythe Plan, oF as remained unrecalved for mo {al tho Heaths Plan Division for assistance. The Plan's grevance process andthe Healt Plan Division's ‘complaint revew prooses arin action to any ther ceputeresakiton procedee that may be availble to You. Your falure to use these procedures does not preclude Your use of any ater remedy provided by tow. Labiity in Event of Non-Payment In the event VSP fist pay the VSP Doctor, You shal ot be fable tothe Doctor for any sums owed by \VSP, aber than those not covered by te Plan Terms and Cancellations “The canract between the Plan and VSP wil conus until termina by either party giving the other party ‘say (60) days prior writen notice Jom for services or benefits which are fled more than one \VSP reserves the ni hunred elghty Vision Benefit Definitions Coated Lenses - A substance is aed to fished lens on one both surlaces Covered Person - The Employee, and the inthis program ble and ented Depends, of he Employer paricpating {Group ~The ent bat contracts wih VSP on boa fis mambors Mateials—Lenses, frame, low vision ads, and contact les, Crthoptics - The teaching and traning process for the improvement of visual percepton and caarinaton ‘of ho wo eyes fr efciont and comerable Bnocular vision, ‘Oversize Lenses ~ Larger than standard lons blank Photochromic Lenses ~ Lonsos that change color wth ntonsty of sunight Plan Administrator - United Adminitatve Services, Plano Lenses - Lenses wih no reactive power, sant lens. Thinner than regular plastic lenses. Appropriat Professional Service ~ Exam, materal selection, tng of glasses, and related achustments sive Lenses —A mulifoallns wth no dete Ines, Changes from distance corrcton in the top ‘the lons to reading corecton inthe botom nal eh lens “Tinted Lenses — Lenses whicn nave addtional substance added o pocice constant tnt (2. pik, gree, 973, andl