|
| Examination |
Every 12 Months
|
Every 12 Months
|
| Lenses |
Every 24 Months
|
Every 24 Months
|
| Frames |
Every 24 Months
|
Every 24 Months
|
| Contact
Lenses |
Every 24 Months
|
Every 24 Months
|
|
| Eye
Examination |
$25 co-pay then 100%
|
$40
|
| Single Lenses |
100%
|
$40
|
| Bifocal
Lenses |
100%
|
$60
|
| Trifocal
Lenses |
100%
|
$80
|
| Frames |
100%
|
$50
|
| Contact
Lenses* (Medically Necessary) |
100%
|
$210
|
| Contact
lenses* (Elective) |
$105
|
$105
|
| Please
note that the above benefits are an overview. Exact coverage
and exclusions are available in the summary plan description
booklet. |
|
*
|
Contact
lens allowance is in lieu of lenses and frames |
Allowance
The above allowances are based on the standard VSP allowance. Any
amount in excess of the VSP allowance will be the responsibility
of the plan participant. The VSP provider will review exact coverage
and exclusions.
Provider Selection
Participants enrolled in the vision plan are always free to obtain
services from the vision provider of their choice. If services are
obtained from a contracted network provider, members will pay their
portion of the negotiated contract charge. If services are obtained
from a non-network provider, members will be responsible for their
portion of the benefit percentage as well as charges above the usual
and customary charges as determined by VSP.
|
