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Voluntary
Vision Plan - VSP
January 1, 2007 – December 31, 2007
Medical
Dental
Vision Vol.
Accident
Life/AD&D
Addt'l Life/AD&D
STD
LTD
LTC
Flex
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Information provided is in summary
format. Any difference between the summary provided and
actual contract will be settled in favor of the contract.
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Vision Exam: |
In-Network |
Out-of-Network
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Time Limit |
One exam every
12 months
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Payment Limit |
$20 Copay |
Up to $45 reimbursement |
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Frames: |
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Time Limit |
One pair
every 24 months
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Payment Limit |
Up to $120 |
Up to
$47 reimbursement |
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Lenses: |
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Time Limit |
One pair every 12 months |
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Payment Limits: |
After $20 Copay (applied to
lenses and frames): |
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Single Vision |
100% |
Up to $47 reimbursement |
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Bifocal |
100% |
Up to $65 reimbursement |
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Trifocal |
100% |
Up to $85 reimbursement |
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Prescription
Contact Lenses: |
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Time
Limit |
One pair every 12 months
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Payment
Limits |
Up to $105 |
Up to $105 reimbursement |
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Member may choose either
frames/lenses or contacts in the stated time periods |
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