VSP/HR/Vision CareVSP Renewal: City of Carmel - 12013661
Effective 5/1/15 to 4/30/17 Two Year Rate Guarantee
u rte._
Exam with Dilation as necessary:
Contact Lens Fitting
(Standard or Premium)
lenaee �'
Single Vision Lenses
Lined Bifocal Lenses
Lined Trifocal Lenses
Lenticular
Frequency:
Frequency.
llamas ,?c rrw, f '
Retail Frame Allowance:
Frame of your choice up to plan allow-
ance, then 20% off overage, In- network
Frequency:
Contact,L,0?$'a 0a y t,
in Iiod ofeyegla�ss beneft,:
Elective Contact Lenses (ECL)
Medically Necessary (NCL)
Frequency:
Member'COSt (or.Cen's�0 dons'; ' f
Standard UV Coating
Solid Tints & Dyes (Pink I & II)
Solid Plastic Dye
Scratch Resistant Coating Standard
Standard Polycarbonate Lenses
Plastic Gradient Dye
Progressive Lenses Standard
Standard Photochromlc Lenses
Standard Anti- Reflective Coating
Other Add -Ons & Services
Frequency:
Primary Eyecare Plan
Employee Only
Employee + One
Employee + Family
,'Current Signature
Plan'
.$10 Copay- r , tip to S50 *..;
rl'115 %0lscount
Once 'er sen+ce year
:S25 Copay '' : Up to S50 .:
sii2S Copay,, . 11Upto$75 ',r
M,S253Copay: i Uptos100:',:
+$25 Copay : `' Up to $t25:; :
Once per service ye ,-- -
;.$150 Allowance
Up CO $70
,S130Allowence = :Up to 3105 -�
Covered In Full ._: Up to 5210
Orx:e per service yeer
: Covered In Full
'013'S..
Covered In Full "
Covered in Full
Discounts do-
not apply to-
515: lens options,
out -ot- network
$50 :`•
E39. -
:20% Discount
Once per service ye,
57.81
$11.93
321.39
vs p..m fa.
�,ro
110 Exam Copayment & 325 Material Copayment - If lenses are not purchased the copayment apples to frames
Copay for material contact lens benefit is SO. Allowance applies to materials.
VSP will determine when contact lenses are necessary on the same basis as with member doctors. Otherwise elective allowance will prevail.
'Prices shown reflect the standard option price for each respective category.
Premium options may vary. Prices are only valid through VSP provider & subject to change.
'Primary Eyecare copay will remain 320 with renewal.
Please Confirm this irdermoticn is correct for dependents covered by the plan
Child(ren)
Q Full -time Student
Domestic Partner 0 Same sex only [' Same & opposite sex
❑� Handicapped Dependent Child(ren) of Domestic Partner
Dependent Coverage: Children and students covered until their 26t5 birthday.
Rate Guarantee: May 1, 2015 through April 30, 2017
To implement the upgraded plan and maintain continuous service, please indicate your selection by checking the box
next to the option you would like. Sign and return the agreement by March 31, 2015. VSP will produce the updated
contract once we receive the signed document. Please review the new contract carefully, since some of the provisions
may have changed from you prior contract. Additionally, please keep a copy of this agreement for your records. Please
return signed form by the above date to prevent coverage disruption.
By:
Title:
Date:
Signature Page Attached
VSP Proprietary & Confidential
2015 VSP Renewal
CITY OF CARMEL, INDIANA
By and through its Board of Public Works and Safety
Date
3/05
Mary Ann B ke, Boar• Member Date
1
Lori Wats -' d Member Date
ATTEST:
TE
Diana Cordray, IAMC, Clerk- Treasurer
Date
1
0
To: Board of Public Works and Safety
From: Barbara Lamb, Director of Human Resources
Date: 2/25/2015
Re: Vision Insurance Renewal
The contract renewal for Vision Service Plan (VSP) is on the March 4, 2015, Board of Public Works
and Safety agenda. VSP provides vision insurance for employees. The vision insurance is wrapped
into the health insurance, and is available only to those who elect the City's health insurance.
This renewal is for the same benefits at the same rate currently in effect, and is guaranteed for two
years. This is a good proposition for the City.
Please call me (571 -2471) prior to the March 4 Board of Public Works and Safety meeting if you have
any questions. I plan to be at the meeting to address any issues that might arise at that time.