• One comprehensive examination in any 12 consecutive months
• One pair of standard lenses in any 12 consecutive months (Standard lenses fit any frame with an eyesize less than 61mm)
• One standard frame in any 24 consecutive months (A standard frame is any frame that has a maximum retail cost of $105.00 or less)
• One pair of contact lenses in any 12 consecutive months. (This benefit is in lieu of lenses and frame)
• If contact lenses are for cosmetic or convenience purposes, the plan will pay up to $105.00 toward their cost. Any balance is your responsibility.

If contact lenses are medically necessary, they are a fully covered benefit:

following cataract surgery; or when visual acuity cannot be corrected to 20/70 in the better eye except through the use of contacts; or when necessitated by anisometropia or certain conditions of keratoconus. Prior authorization from Vision Service Plan is required.

BENEFITS PROVIDED BY NON-PARTICIPATING PROVIDERS:

If covered services and/or materials are provided by a non-participating provider, charges will be paid but not to exceed the following Schedule of Allowances:

*This allowance is in lieu of other eyewear.

Benefit frequencies are the same as listed under the participating providers section.

HOW TO USE THE PLAN:

Participating providers will submit the claim form to Vision Service Plan and are paid directly. If you do not bring your claim form with you at the time of your visit, you may be required to pay in full for the services.

If services are received from a non-participating provider, reimbursement will be made to the insured up to the Schedule of Allowances. You, or the provider should submit an itemized billing and a copy of your prescription with the claim form to Vision Service Plan.

LIMITATIONS:

• Lenses or frames which were furnished under the plan and which have been lost, stolen or broken will not be replaced, except when benefits are otherwise available.
• Eyewear when there is no prescription change, except when benefits are otherwise available.
• Lenses such as no-line (blended type), varilux (progressive), flat-top 35, executive-style, coated, oversized, hi-index, polycarbonate, beveled or faceted, will be limited to the Schedule of Allowances.
• Contact lenses will be limited to the Schedule of Allowances.

EXCLUSIONS:

• Conditions covered by Workers’ Compensation.
• Services which begin prior to the insured’s effective date or after benefits have terminated.
• Services and supplies in connection with special procedures such as: orthoptics or vision training and subnormal vision aids.
• Non-prescription (plano) eyewear.
• Frame cases.
• Tints, other than Rose and Pink #1 and #2, except when noted.
• Contact lens fitting charges.
• Contact lens insurance, care kits and supplies.
• Medical or surgical treatment of the eyes.
• Charges for which the insured is not required to pay.
• Eye examinations required by an employer as a condition of employment.
• Any service or material provided by another vision plan.

If you have any questions about the plan, please contact the Vision Service Plan office.

www.vsp.com
[email protected]
800.877.7195

THIS IS A BRIEF OUTLINE OF THE PLAN AND IS NOT TO BE ACCEPTED OR CONSTRUED AS A SUBSTITUTE FOR THE PROVISIONS OF THE CONTRACT.