WithoutVision Plus

WithVision Plus

Eye Exam $134 $0 Copay

Frame $150

$0 CopayBifocalLenses $134

Progressives $137 $40 Copay

Anti-reflectiveCoating $106 $69

Annual Contribution(You Only)

N/A $115.44

Total $527 $224.44

AverageAnnual Savings

$302.56with a VSP

Doctor

Enroll in VSP® Vision Plus

Contact us.vsp.com/go/chevron | 800.877.7195

See what VSP can do for you. Personalized CareYou get personalized care and a great eyewear selection—all in one location with a VSP provider. When you see a VSP provider, you’ll get the most out of your benefit and have lower out-of-pocket costs. Plus, you’ll be 100% happy with a VSP provider or call us and we’ll make it right.

VSP providers also take the time to get to know you and your eyes. Through a Well Vision Exam®, they’ll look for vision problems and signs of other health conditions like high blood pressure and diabetes.

Choice of Providers With open access to see any eyecare provider, you can see the one who’s right for you. Choose a VSP doctor, Costco® provider, or an out-of-network provider. To find a VSP provider, visit vsp.com/go/chevron or call 800.877.7195. Costco is an out-of-network provider; however, they can submit claims directly to VSP on your behalf.

Great Eyewear You can choose the eyewear that’s right for you and your budget. From classic styles to the latest designer frames, you’ll find hundreds of options. Choose from featured frame brands like Anne Klein, bebe®, Calvin Klein, Flexon®, Lacoste, Nike, Nine West, and more.1

Visit vsp.com to find a VSP provider who carries these brands.

Look for VSP during open enrollment.

Value and Savings See how much you can save with the

Vision Plus prescription eyewear buy-up option:

Comparison is based on national averages for most commonly purchased brands. Contribution will be slightly higher if you waive Chevron-offered medical coverage. For Chevron U.S.- payroll employees only. Rates effective January 1, 2015.

During open enrollment, you can enroll in coverage for a

prescription eyewear buy-up option called Vison Plus. This benefit

is optional and offers prescription eyewear coverage for you and

your eligible dependents. If you elect this coverage, there is an

additional monthly premium deducted pretax from your paycheck.

Save more on prescription eyewear for you and your eligible dependents.

Using your VSP benefit is easyRegister at vsp.com. Once your plan is effective, review your benefit information.

Find an eyecare provider who’s right for you. To find a VSP provider, visit vsp.com or call 800.877.7195. At your appointment, tell them you have VSP. There’s no ID card necessary. If you’d like a card as a reference, you can print one on vsp.com.

That’s it! We’ll handle the rest—there are no claim forms to complete when you see a VSP provider.

CopayDescriptionBenefit Frequency

Your VSP Vision Benefits SummaryChevron and VSP provide you with an affordable Vision Plus prescription eyewear buy-up option.

VSP Coverage Effective Date: 01/01/2015VSP Provider Network: VSP ChoiceCoverage for Chevron U.S. -payroll employees only.

Visit vsp.com/go/chevron for more details on your vision benefit and for exclusive savings

and promotions for VSP members.

VSP guarantees coverage from VSP network providers only. Coverage information is subject to change. In the event of a conflict between this information and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location.

Your Coverage with a VSP Provider

WellVision Exam® • Focuses on your eyes and overall wellness $0 Every calendar year

Prescription Glasses

Frame

• $150 allowance for a wide selection of frames, or• $170 allowance for featured frame brands, and• 20% savings on the amount over your allowance

or• $70 allowance at Costco®

$0 Every calendar year

Lenses • Single vision, lined bifocal, and lined trifocal lenses• Polycarbonate lenses for children $0 Every calendar year

Lens Enhancements• Progressives• Standard progressive lenses at Costco• Average savings of 20% – 25% on other lens enhancements

$40$40 Every calendar year

Contacts (instead of glasses)

• $150 allowance for contact; copay does not apply• Contact lens exam (fitting and evaluation) Up to $60 Every calendar year

Extra Savings

Glasses and Sunglasses• 20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12

months of your last WellVision Exam.

Retinal Screening• No more than a $39 copay on routine retinal screening as an enhancement to your WellVision Exam.

Laser Vision Correction• Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities

Your Coverage with Out-of-Network Providers (Out-of-network coverage is in lieu of network coverage.)

Visit vsp.com for details, if you plan to see a provider other than a VSP network provider.

There are no claim forms to complete with Costco, and with their current prices, your single, bifocal, and trifocal lenses may be fully covered.

Exam ............................ up to $45 Single Vision Lenses ......up to $30 Lined Trifocal Lenses .....up to $65Frame .......................... up to $70 Lined Bifocal Lenses ......up to $50 Contacts .................................up to $105

Enroll in VSP today. You’ll be glad you did.Contact us. vsp.com | 800.877.7195

©2014 Vision Service Plan. All rights reserved.VSP, VSP Vision care for life, and WellVision Exam are registered

trademarks of Vision Service Plan. Flexon is a registered trademark of Marchon Eyewear, Inc. All other brands are trademarks or registered

trademarks of their respective owners.

1. Brands/Promotion subject to change.

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