HomeMy WebLinkAboutVision Service Providers/HR/VSP Renewal 2024CzTfshfzHsfdivlijobu4;3:qn-Pdu34-3134
VSPRenewalExhibitfor CityofCarmel
Group Number: 12013661
RenewalEffective Date: January1, 2024
VSP Signature PlanVSP Signature PlanVSP Signature Plan
Current PlanRenewal PlanRenewal Alternative Option
10.00$10.00$10.00ExamCopay
25.00$25.00$25.00MaterialsCopay
Frequency:
Every 12 MonthsEvery 12 MonthsEvery 12 MonthsExam:
Every 12 MonthsEvery 12 MonthsEvery 12 MonthsLenses:
Every 24 MonthsEvery 24 MonthsEvery 24 MonthsFrame:
Essential Medical Eye Care
20 copay per visit$20 copay per visit$20 copay per visit
Exam Coverage
Covered in full after copayCovered in full after copayCovered in full after copayWellVisionExam
Standard and premium fit: Covered in full after Standard and premium fit: Covered in full after Standard and premium fit: Covered in full after
copay. Member receives 15% off contact lens exam copay. Member receives 15% off contact lens exam copay. Member receives 15% off contact lens exam
services; copay will never exceed $60 services; copay will never exceed $60 services; copay will never exceed $60ContactLensExam
Fitting & Evaluation)
15% off not available at Costco Optical, 15% off not available at Costco Optical, 15% off not available at Costco Optical,
Walmart Optical or Sam's Club OpticalWalmart Optical or Sam's Club OpticalWalmart Optical or Sam's Club Optical
Routine Retinal Screening
No more than a $39 copay on routine retinalt® Not available at Costco Optical, WalmartNo more than a $39 copay on routine retinal No more than a $39 copay on routine retinalscreeningasanenhancementtoaWellVisionscreeningasanenhancementtoaWellVisionExamscreeningasanenhancementtoaWellVisionExamOpticalorSam's Club Optical Exam
Lens Coverage
Basic Prescription Lenses:
Glass or plastic)
Single vision Covered in full after copayCovered in full after copayCovered in full after copay
Lined bifocal
Lined trifocal
Lenticular
1 Covered with a copay, saving an average of Covered with a copay, saving an average of Covered with a copay, saving an average ofLensEnhancements
40%40%40%
Single VisionMultifocalSingle VisionMultifocalSingle VisionMultifocal
Standard Anti-Glare coating: 37$37$37$37$37$37
All other Anti-Glare coatings:$61 - $75$61 - $75$61 - $75$61 - $75$61 - $75$61 - $75
Impact-resistant lenses for children:Covered in fullCovered in fullCovered in fullCovered in fullCovered in fullCovered in full
Impact-resistant lenses for adults:Covered in fullCovered in fullCovered in fullCovered in fullCovered in fullCovered in full
Standard Progressives:N/ACovered in fullN/ACovered in fullN/ACovered in full
Premium & Custom Progressives:N/A$80 - $160N/A$80 - $160N/A$80 - $160
Tints/Light-reactive lenses:$70$70$70$70$70$70
Scratch-resistant coating:Covered in fullCovered in fullCovered in fullCovered in fullCovered in fullCovered in full
Costco Optical, Walmart Optical and Sam'sCostco Optical, Walmart Optical and Sam's ClubCostco Optical, Walmart Optical and Sam's Club
Optical prices already include savings. Members will Optical prices already include savings. Members willClubOpticalpricesalreadyincludesavings.
pay the Usual & Customary fee.pay the Usual & Customary fee. Members will pay the Usual & Customary fee.
1Prices shown reflect standard selections; premium or custom options may also be available at additional costs.
Frame Coverage
150 allowance; plus 20% off any amount above the $150 allowance; plus 20% off any amount above the $200 allowance; plus 20% off any amount above the
VSP Network Doctors and Visionworks allowanceallowanceallowance
80 allowance$80 allowance$110 allowanceCostcoOptical
Walmart Optical, Sam's Club Optical 130 allowance $130 allowance $200 allowance
and Retail Chains
Contact Lens Coverage
Elective Contact Lenses 130 allowance$130 allowance$150 allowance
prescription contact lenses, in lieu of glasses)
Necessary Contact Lenses
Covered in full after copayCovered in full after copayCovered in full after copayNotavailableatRetailChains, Costco Optical,
Walmart Optical or Sam's Club Optical
Extra Savings
Average 15% off or 5% off promotional offerAverage 15% off or 5% off promotional offerAverage 15% off or 5% off promotional offer
SMVSPLaserVisionCareProgram Discounts only available from VSP contracted Discounts only available from VSP contracted Discounts only available from VSP contracted
Discounts on LASIK, Custom LASIK, and PRK, facilities.facilities.facilities.
plus patient education. Members who've had laser surgery can use frame Members who've had laser surgery can use frame Members who've had laser surgery can use frame
benefit for non-prescription sunglassesbenefit for non-prescription sunglassesbenefit for non-prescription sunglasses
30% off unlimited additional pairs of prescription 30% off unlimited additional pairs of prescription 30% off unlimited additional pairs of prescription
glasses and/or non-prescription sunglasses glasses and/or non-prescription sunglasses glasses and/or non-prescription sunglasses
purchased on the same day with the same provider purchased on the same day with the same provider purchased on the same day with the same provider
Additional Pairs of Glasses who performed the exam. Or 20% off from any VSP who performed the exam. Or 20% off from any VSP who performed the exam. Or 20% off from any VSP
provider within 12 months of the member's last provider within 12 months of the member's last provider within 12 months of the member's last
WellVision ExamWellVision ExamWellVision Exam
Plan Enhancements
LightCare
Allows members to use their frame allowance
towards ready-made non-prescription
sunglasses, or ready-made non-prescription blue $25 copayN/AN/A 200 allowancelightfilteringglasses, instead of prescription
glasses or contacts.
Not available at Walmart Optical or Sam's Club
Optical
Out-of-Network Schedule
50.00$50.00$50.00EyeExam:
50.00$50.00$50.00SingleVision:
75.00$75.00$75.00LinedBifocal:
100.00$100.00$100.00LinedTrifocal:
125.00$125.00$125.00Lenticular:
75.00$75.00$75.00Progressive:
70.00$70.00$70.00Frame:
105.00$105.00$105.00ElectiveContactLenses:
210.00$210.00$210.00NecessaryContactLenses:
Rate PassMonthlyRates
Employee Only: $8.20Employee Only: $8.03Employee Only: $8.20
Employee + One: $12.53 Employee + One: $12.27 Employee + One: $12.53Risk
Employee + Family: $22.46Employee + Family: $22.01Employee + Family: $22.46
Sliding 10%Sliding 10%Sliding 10% Commissions
2 Years2 Years4 YearsPolicyTerm
Select the desired renewal plan
Renewal Acceptance
To renew your contract with VSP and ensure continuous service, please have the appropriate representative review this information, select the desired renewal action, sign and return this Renewal
Agreement to the email address below. VSP produces your Plan Policy upon receipt of your confirmation of renewal. Your new Plan Policy may contain some provisions that are changed from those
in your current Policy, so you should review the new Policy carefully upon receipt. Please file this Agreement with your VSP contract as it serves as your notice of renewal.
VSP® Renewal Exhibit for City of Carmel
Renewal Effective Date: January 1, 2024
Kiley EllisSignature:
Key Client Manager, VSPName:
800.852.7600 Ext.7442Title:
kiley.ellis@vsp.comDate:
Based onapplicable laws, benefits may varybydoctor location.
2023 Vision Service Plan. All rights reserved.
Classification: Confidential
Rev. 08/2023
DocuSign Envelope ID: 04372EEB-5867-4A05-9261-64610CF6A961
Approved and Adopted this ______ day of __________________, 20______.
CITY OF CARMEL, INDIANA
By and through its Board of Public Works and Safety
BY:
James Brainard, Presiding Officer
Date: _____________________________________
Mary Ann Burke, Member
Date: _____________________________________
Lori S. Watson, Member
Date: _____________________________________
ATTEST:
SueWolfgang, Clerk
Date: _____________________________________
DocuSign Envelope ID: 04372EEB-5867-4A05-9261-64610CF6A961
Not Present
N/A
1st November 23
11/1/2023
11/1/2023
11/1/2023