Expatriate Vision Plan

2020 and 2021 Plan Year Information

VSP Network Provider Eye Exam Option A

In-Network:
100% after $20 copay

Out-of-Network:
Up to $50 allowance after $20 copay

Vision Benefits

The benefits in the chart above are available once per calendar year, except for frames, which are covered once every two calendar years. Many services are covered at 100% after copay when you use in-network providers. You may also receive discounts on services at participating retail chain stores such as Cohen’s Fashion Optical, Costco and others.

VSP Option B
Note

The figures in the chart below reflect what the Plan pays, with the exception of deductibles and out-of-pocket maximums.

Eye Exam

In-Network:
100% after $20 copay

Out-of-Network:
Up to $40 allowance after $20 copay

Frames

In-Network:
Up to $150 after $20 copay plus 20% discount on cost exceeding $150 every two years

Out-of-Network:
Up to $60 allowance after $20 copay

Lenses: Single

In-Network:
100% after $20 copay for lenses and frames

Out-of-Network:
Up to $40 allowance after $20 copay

Lenses: Lined Bifocal

In-Network:
100% after $20 copay for lenses and frames

Out-of-Network:
Up to $60 allowance after $20 copay

Lenses: Lined Trifocal

In-Network:
100% after $20 copay for lenses and frames

Out-of-Network:
Up to $75 allowance after $20 copay

Lenses: Progressive

In-Network:
100% after $20 copay for lenses and frames

Out-of-Network:
Up to $60 allowance after $20 copay

Optional Lens Types and Treatments

In-Network:
100%

Out-of-Network:
5%

Elective Contact Lenses (instead of eyeglasses)

In-Network:
Up to $150 and $60 max copay for contact lens exam

Out-of-Network:
Up to $100 (includes exam and fitting)

Medically Necessary Contact Lenses with VSP Approval

In-Network:
100% after $20 copay for exam and $20 copay for lenses once every two years

Out-of-Network:
Up to $210 allowance after $20 copay

Diabetic Eyecare Plus

$20 copay for additional eyecare services specifically for members with diabetic eye disease, glaucoma or age-related macular degeneration (AMD)

Notes About Lenses and Frames

The total copay for lenses generally applies to both eyeglass lenses and/or frames. You may select from a variety of optional lens types, as outlined in the Health Benefits and Insurance SPD.

Lenses are considered medically necessary for certain eye conditions that prohibit the use of glasses, including aphakia, anisometropia, high ametropia, nystagmus and keratoconus.

If you purchase frames from Costco, the frame allowance is $135 for VSP Option A and $80 for VSP Option B.

Other Vision Services

Services such as laser surgery, low vision supplemental testing, additional prescription and nonprescription glasses and sunglasses, and contact lens exams are covered to the extent described in the schedule of benefits in the Health Benefits and Insurance SPD.

FSAs

Flexible Spending Accounts (FSAs) allow you to set aside before-tax money to use for certain eligible expenses not covered by your health plans or to pay for certain dependent day care expenses. Using an FSA can save you from 20% to 40% depending on your tax bracket.

The Firm offers three types of FSAs: a Health Care FSA, a Limited Purpose FSA* and a Dependent Day Care FSA. The Health Care and Dependent Day Care FSAs are administered by UnitedHealthcare (UHC). The Limited Purpose FSA is administered by Your Savings Account.

*The Limited Purpose FSA is only available to employees enrolled in Medical Plan Option C and can only be used for eligible dental and vision expenses.

Vision Contributions

You pay the full cost of vision coverage. Your contributions are deducted from your pay on a before-tax basis.

2021:

 Yourself OnlyYourself + Spouse/Domestic PartnerYourself + ChildrenYourself + Family
VSP Vision Plan A Cost$8.90$17.80$19.04$30.44
VSP Vision Plan B Cost$6.57$13.12$14.04$22.43

*The costs shown are per paycheck contributions. For the monthly cost, double the amounts shown.

If you are covering a domestic partner or the children of a domestic partner, the final determination of the tax status of a dependent is made by the IRS. As a result, there is no guarantee that the IRS will not impose a tax on the value of coverage.