Vision
Healthy eyes and clear vision are an important part of your overall health and quality of life. You may enroll yourself and your eligible dependents or you may waive vision coverage. You do not have to be enrolled in medical coverage to elect vision coverage or cover the same dependents under medical and vision.
Although vision care services and supplies are covered in-network and out-of-network, your benefits are generally greater when you use in-network providers. Your costs are based on the family members you choose to cover.
Vision Plan 1
Plan Information
Plan Name: Vision Service Plan Premier
Policy Number: 001001
Effective Date: 01/01/2025
Provider Network: VSP
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Exams
$10 copay, then 0%
Materials
$25 copay, then 0%
Frames
Reimbursed up to $130, plus a 20% discount from the remaining balance
Lenses
Single Vision: 100% of basic lens*
Bifocal: 100% of basic lens*
Trifocal: 100% of basic lens*
Contacts (in lieu of glasses)
Reimbursed up to $130 (copay waived)
Frequency
Exams
Once every 12 months
Frames
Once every 24 months
Lenses
Once every 12 months
Contacts
Once every 12 months
*Material copay applies
**In-network limitations apply
Out-of-Network
Exams
$10 copay, then 0% (reimbursed up to $40)
Materials
$25 copay, then 0%**
Frames
Reimbursed up to $47
–
Lenses
Single Vision: Reimbursed up to $40
Bifocal: Reimbursed up to $60
Trifocal: Reimbursed up to $80–
Contacts (in lieu of glasses)
Reimbursed up to $105**
Frequency
Exams
Once every 12 months
Frames
Once every 24 months
Lenses
Once every 12 months
Contacts
Once every 12 months
Plan Documents
Vision Plan 1 Summary
Contact Information
Vision Plan 2
Plan Information
Plan Name: Aetna HMO
Policy Number: 001002
Effective Date: 01/01/2025
Provider Network: Aetna
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Exams
100% covered
Materials
$25 copay
Frequency
Exams
Once every 12 months
Frames
Once every 12 months
Lenses
Once every 12 months
Contacts
Once every 12 months
Plan Documents
Vision Plan 2 Summary