Sample Benefit Enrollment Guide

Company Name Vision Plan

Your VSP Network is the Choice Plan Network. Visit the VSP website at vsp.com to find a complete listing of participating providers.

NOTE: VSP does not issue ID Cards. Your provider can use your Social Security Number to look up your coverage information.

When you need services, consider using an in-network provider for the maximum level of coverage for your vision benefits.

In-Network (You Pay)

Out-of-Network (You Pay)

Eye Exam

Frames

Standard Plastic Lenses

Single Vision Bifocal Trifocal

Contact Lenses* (Including fit, follow-up and materials; in place of standard lenses):

Copay Allowance Wholesale/Retail

Vision Correction Procedures

Lasik

Frequencies

Exams, Lenses and Contacts Frames

20