PremierPlan

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» Resources
» In-Network Coverage
» Computer VisionCare Enhancement
» Progressive Lenses Enhancement
» Out-of-Network Coverage
» Monthly Rates





Resources



In-Network Coverage

     
WellVision Eye Exam
» Frequency       12 Months
» Exam       Free
» Digital Retinal Scan       $39 Co-Pay
 
Materials
» Frequency       12 Months
» Deductible       Free
 
Lenses
» Frequency       12 Months
» Single Vision       Free
» Lined Bifocal       Free
» Lined Trifocal       Free
» Standard Progressives       Free
» Premium Progressives       $95-$105 Co-Pay - Choice Network
        $80-$90 Co-Pay - Signature Network
» Custom Progressives       $150-$175 Co-Pay - Choice Network
        $120-$160 Co-Pay - Signature Network
» High Index       30% Average Discount - Choice Network
        40% Average Discount - Signature Network
» Polarized       30% Average Discount - Choice Network
        40% Average Discount - Signature Network
» Impact-Resistant       30% Average Discount - Choice Network
        40% Average Discount - Signature Network
 
Lens Customizations
» Polycarbonates for Children       Free
» Polycarbonates for Adults       Free
» Transitional (Photochromic)       Free
» Tinting       Free
» Scratch-Resistant       30% Average Discount - Choice Network
        40% Average Discount - Signature Network
» Anti-Reflective Coatings       30% Average Discount - Choice Network
        40% Average Discount - Signature Network
» UV Coatings       30% Average Discount - Choice Network
        40% Average Discount - Signature Network
» Other Lens Customizations       30% Average Discount - Choice Network
        40% Average Discount - Signature Network
 
Frames
» Frequency       12 Months
» Coverage       $170 Allowance
» Featured Brand Coverage       $190 Allowance
» Coverage After Allowance       20% Discount
 
Extra Savings
» Additional Glasses       20% Discount
» Additional Sunglasses       20% Discount
» Blue-Light Filtering Glasses       20% Discount
 
Contact Lenses
(Instead of Lenses and/or Frames)
» Frequency       12 Months
» Coverage       $150 Allowance
» Fitting & Evaluation Exam       Max $60 Co-Pay
» Medically Necessary Contacts       Free
 
Laser Vision Surgery
» Coverage       Discounted
 
Essential Medical Eye Care Services
» Coverage       $20 Co-Pay
» Services       Retinal Screening for Diabetics
        Medical Exams & Services for diagnosis, treatment, & management of chronic conditions, such as diabetic eye disease, glaucoma, & age-related macular degeneration.
        Treatment for Urgent Conditions such as eye infections, foreign body & abrasions, eye injuries, & eye or eyelid chemical exposure.
        Medical Tests for diagnosis & treatment of sudden vision changes, such as eye flashes, floaters, & sudden vision loss.
        Other Vision Medical Services
 
Hearing
» Frequency       12 Months
» Digital Hearing Aids       Up to 60% Discount
» Online Hearing Test       Free
» Hearing Aid Batteries       120 for $39


Computer VisionCare Enhancement

The optional Computer VisionCare enhancement provides additional computer vision specific coverage for the Employee Only. After an employee completes a simple questionnaire, and pays a $25 Co-Pay, they will receive a supplemental, limited eye exam to determine their specific visual needs for computer use. After this eye exam, if it is prescribed, employees will receive an additional pair of glasses to meet their computer use needs for Free.



Progressive Lenses Enhancement

This optional enhancement can be added to any base plan for a small additional cost. It makes Premium & Custom Progressive Lenses available at the Materials Deductible, instead of the more expensive Co-Pays under the base plan design.



Out-of-Network Coverage

Members can utilize out-of-network providers, but they will be required to pay the provider in full at the time of service. Members can then apply for a partial reimbursement directly from VSP using the Out-of-Network Reimbursement Form. Claims must be filed within 6 Months of the date of service. Members may receive up to the following reimbursement allowances for out-of-network services after any applicable co-pays or deductibles:
         
    ChoiceNetwork   SignatureNetwork
 
» Exam        45        50
» Frames        70        70
» Single Vision Lenses        30        50
» Bifocal Lenses (Lined or No-Line)        50        75
» Trifocal Lenses (Lined or No-Line)        65        100
» Progressive Lenses        50        75
» Lenticular Lenses        100        125
» Elective Contacts        105        105
» Medically Necessary Contacts        210        210




Monthly Rates

Employer Sponsored Rates are for when employees pay less than 50% of the premium.
Voluntary (Employee Paid) Rates are for when employees pay more than 50% of the premium.

PremierPlan
    ChoiceNetwork   SignatureNetwork
    Employer   Voluntary   Employer   Voluntary
    Sponsored   (Employee Paid)   Sponsored   (Employee Paid)
Member   16.24   19.48   17.98   21.74
Spouse & Member   24.24   28.74   27.24   32.48
Child(ren) & Member   24.74   29.24   27.74   32.98
Family   39.24   45.98   44.24   51.98


PremierPlan
with Progressive Lenses Enhancement
    ChoiceNetwork   SignatureNetwork
    Employer   Voluntary   Employer   Voluntary
    Sponsored   (Employee Paid)   Sponsored   (Employee Paid)
Member   17.98   21.24   20.24   23.74
Spouse & Member   27.24   32.24   30.48   35.98
Child(ren) & Member   27.74   32.24   30.98   35.48
Family   43.98   52.24   48.98   58.24


PremierPlan
with Computer VisionCare Enhancement
    ChoiceNetwork   SignatureNetwork
    Employer   Voluntary   Employer   Voluntary
    Sponsored   (Employee Paid)   Sponsored   (Employee Paid)
Member   17.98   20.74   20.24   23.74
Spouse & Member   26.24   30.48   29.48   33.98
Child(ren) & Member   26.48   30.98   29.98   34.98
Family   40.98   47.98   45.74   53.48


PremierPlan
with Computer VisionCare & Progressive Lenses Enhancements
    ChoiceNetwork   SignatureNetwork
    Employer   Voluntary   Employer   Voluntary
    Sponsored   (Employee Paid)   Sponsored   (Employee Paid)
Member   19.48   22.98   21.74   25.48
Spouse & Member   28.48   33.24   31.98   37.24
Child(ren) & Member   28.98   33.48   32.48   37.48
Family   44.98   53.24   50.48   59.74