VSP PROVIDER BENEFITS |
NON-VSP PROVIDER REIMBURSEMENT AMOUNTS |
|
|---|---|---|
| Vision Exam (once per calendar year) |
100% after $15 copay | Up to $40 |
| Eyeglass Lenses (once per calendar year) |
100% after $15 copay1 | Up to $40 (Single Vision) Up to $60 (Bifocal) Up to $80 (Trifocal) Up to $125 (Lenticular) |
| Frames Adult (every two calendar years) Child (once per calendar year) |
100% after $15 copay (up to $200) |
Up to $40 |
| Necessary Contacts2 (once per calendar year) Contact Lens Evaluation, Fitting Fees and Contact Lenses |
100% after $15 copay | Up to $210 |
| Elective Contacts3 (once per calendar year) Contact Lens Evaluation, Fitting Fees and Contact Lenses |
Up to $200 | Up to $105 |