VSP Renewal/HR VSP Renewal: City of Carmel-12013661
Effective 5/1/13 to 4/30/15 Two Year Rate Guarantee V S l:(�
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Current Signature Renewal Signature Plan
Plan
-- . Open Access
Network' - �i4ri l0 Network GG�7-B' r
Exam with Dilation as necessary: $10 Copay Up to$50 $10 Copey Up to$50
Contact Lens Fitting 15%Discount 15%Discount
(Standard or Premium)
Frequency Once per service year Once per service year
Single Vision Lenses $25 Copay y 4 Up to$50 $25 Copay Up to$50
Lined Bifocal Lenses $25 Copay Up to$75 $25 Copay Up to$75
Lined Trifocal Lenses $25 Copay Up to$100 $25 Copay Up to$100
Lenticular $25 Copay Up to$125 $25 Copay Up to$125
Frequency: Once per service year Once per service year CU
•
Retail Frame Allowance: $150 Allowance Up to S70 $150 Allowance Up to$70
Frame of your choice up to plan allow-
ance,then 20%off overage,In-network
Frequency: Once every other service year Once every other service year
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Canted Lenaea{.` - - - "
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Elective Contact Lenses(ECU $130 Allowance""—Up to 5105 $130 Allowance Up to 5105
Medically Necessary(NCLI Covered In Full Up to$210 Covered In Full Up to$210 •,
Frequency: _ 9nce per service year Once per service year U.
Member Coat for Lane Options'. _
Standard UV Coating $14 1 $14
Solid Tints&Dyes(Pink I B II) Covered In Full Covered In Full
Solid Plastic Dye $13 513
Scratch Resistant Coating Standard Covered In Full Discounts do Covered in Full Discounts do
Standard Polycarbonate Lenses Covered In Full trot apply to Covered In Full not apply to
Plastic Gradient Dye $15 lens options S15 lens options
Progressive Lenses Standard $50 out-of-network $50 outof-network
Standard Photochromlc Lenses $62-570 ` r 562-576
Standard AnbReilective Coating $39 $37
Other Add-Ons&Services 20%Discount 20%Discount
Frequency Once per service year _ Once per seMce year
Primary Eyecare Plan ' $20^Y^ $20
Risk;' y:1.•:,h<' .. __ - ...
Employee Only• $7.02 $7.81
• Employee+One $10.72 $11.93
Employee+Family $19.22. $21.39
1$10 Exam Copayment&$25 Material Copoyment-If lenses are not purchased then copayment applies to frames
'Copay for material contact lens benefit is$0. 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 coney will remain$20 with renewal.
Please Confirm this information is correct for dependents covered by the plan
❑' Child(ren) El Domestic Partner ❑ Same See only ❑' Same&opposite sax
Q Full-time Student Q Handicapped Dependent Q Child(ren)of 0mestic Partner
Dependent Coverage:Children and students covered until(heir 26'"birthday.
Rate Guarantee: May 1,2013 through April 30,2015
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 31,2013. VSP will produce the updated
contract once we receive the signed document. Neese 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.
Tide:
Signature Page Attached
Date:
VSP Proprietary&Confidential
CITY OF CARMEL, INDIANA
By and through its Board of Public Works and Safety
I �_ =-' _I 3A 4/.3
ter -es Brainard, Presiding Officer Date
3rte- J3
Mar Ann urke, Board Member Date
. , 3 / /(3
Lori Waist , 1oard Member Date /
ATTEST: Ai/4 . i�/I.-_n' .. i,t ,,,,,-/
Diana Cordray, IA W"Jerk reasurer Date
1