2021 Apple Vision Plan Overview

Plan Name Vision Service Plan (VSP)

Group #: 00865701
Member Services: 877-666-2185

Overview The summary below highlights some of the features of the AppleVision Plan. For comprehensive
details about the plan, see the Apple Benefits Book.

When you use a VSP participating provider, the Apple Vision Plan provides a higher level of
coverage, which will save you and Apple money, since payments are based on negotiated rates.

How the Apple Vision Plan Works

Network Type In-Network Out-of-Network

Annual Eye Exam 100%; once every 12 months $50 maximum benefit; once every 12 months
Exam includes retinal screening

Glasses-Lenses UV protection covered in full $50-$125 benefit based on lens type, after a
$10 copay for anti-reflective coating $10 copay
Medically necessary Pink 1 and 2 tinted lenses: UV protection and anti-reflective coating:
Covered in full Not covered
One set every 12 months Medically necessary Pink 1 and 2 tinted lenses:
Not covered
One set every 12 months

Glasses-Frames $10 copay; up to $150 retail frame allowance $70 maximum benefit, after a $10 copay
(20% discount for amounts over allowance) One set every 12 months
One set every 12 months

Contacts, Elective $150 maximum benefit $110 maximum benefit

Contacts, Visually Necessary Covered in full, after a $10 copay $210 maximum benefit, after a $10 copay

Supplement Care Aids Requires precertification for the Low Vision benefit.
75% of VSP approved amount after 25% copay, up to $1000 every two years, restrictions apply

Laser Vision Surgery Not a covered benefit; however, VSP offers discounts averaging 15% off of provider’s usual and
customary price for PRK, Lasik and Custom Lasik.

Before-Tax Cost

Employee Per Pay Period: Full-Time: $1.22 / Part-Time: $1.30

Per Month: Full-Time: $2.64 / Part-Time: $2.82
Per Year: Full-Time: $31.68 / Part-Time: $33.84

Employee + Spouse or Domestic Partner Per Pay Period: Full-Time: $2.69 / Part-Time: $5.51
Per Month: Full-Time: $5.83 / Part-Time: $11.94
Per Year: Full-Time: $69.96 / Part-Time: $143.28

Employee + Child(ren) Per Pay Period: Full-Time: $2.22 / Part-Time: $4.36

Per Month: Full-Time: $4.81 / Part-Time: $9.45
Per Year: Full-Time: $57.72 / Part-Time: $113.40

Employee + Family Per Pay Period: Full-Time: $3.72 / Part-Time: $8.58

Per Month: Full-Time: $8.06 / Part-Time: $18.59
Per Year: Full-Time: $96.72 / Part-Time: $223.08

The Apple Vision Plan Chart highlights commonly used services and generally indicates how you and the vision plan will cover vision expenses you
and/or your enrolled dependents incur. Some services are subject to frequency and coverage limits. This chart does not reflect all covered services,
plan exclusions, limitations or restrictions. It is not a contract or guarantee of coverage. See the Apple Benefits Book for more information.

2021 Apple Vision Plan Overview 1