Health and Welfare Summary Plan Description

• Health and Welfare SPD / Article XI / Supplemental Benefits >>

11.2 Vision Benefits.

1. General Rules. Vision benefits are available to all Covered Individuals. The Plan's vision benefits are paid directly from the Trust (i.e., they are not insured). The program is administered by Vision Service Plan ("VSP"), Group #12140808. See the VSP handout for additional information.
2. Benefits. Vision benefits include an eye examination and new lenses (for glasses and contacts) every 12 months, and new frames every 24 months. These benefits also include full coverage for safety frames with prescription lenses through your VSP provider, every 24 months for a $10 copay. A 20% discount on non-covered complete pairs of prescription glasses with a VSP provider is available when ordered within 12 months of your well-vision exam, or a 30% discount if ordered the same day of your well-vision exam. A complete listing of VSP participating providers is available from the Plan Office. You may also contact VSP customer service at (800) 877-7195, or visit the company's web site at vsp.com.
3. Coinsurance. If you use a participating VSP provider, you must pay a $10.00 coinsurance plus additional payment for certain cosmetic or elective eyewear options.
   
4. How to Use the Plan. Call your VSP provider to make an appointment. Identify yourself as a San Francisco Electrical Workers Health & Welfare Plan VSP member and provide your name, date of birth and Social Security number. The provider will then verify your eligibility and deal directly with VSP for reimbursement for services and materials that are covered by the Plan. You simply pay your providers for the coinsurance and any other costs that are not covered.
   
5. Out-of-Network Providers. VSP will reimburse you up to the amount allowed under the Plan's out-of-network provider reimbursement rate if you are treated by a provider outside of the VSP network.
   

   OUT-OF-NETWORK Maximum Benefits

   Examination	$ 50.00
   Single Vision Lenses	$ 50.00
   Bifocal Lenses	$ 75.00
   Trifocal Lenses	$ 100.00
   Frame	$ 70.00 (every 24 months, effective 8/2014)
   Contact Lenses	$ 105.00
   Medically Necessary Contact Lenses	$ 210.00

   
   A copy of the provider's itemized bill with all of the pertinent Plan and patient information should be submitted directly to Vision Service Plan, Attn.: Out-of-Network Claims, P. O. Box 997100, Sacramento, CA 95899-7100.