Vision
Vision benefits, administered by Vision Service Plan (VSP), are included with the Standard and Enhanced medical
plans. For a provider directory and to access other features, visit vsp.com or call the VSP customer service line at
800-877-7195. When scheduling an appointment, identify yourself as a VSP member and provide your member ID
number (your Social Security number). There are no cards or claim forms.
Benefit Description: Your coverage with VSP Doctors and Affiliate Providers Copay
WellVision Exam Focuses on your eyes and overall wellness
Every 12 months $25 for exam
and glasses
Prescription Glasses
Frame $150 allowance for a wide selection of frames
20% off amount over your allowance
$80 allowance at Costco Optical
Every 24 months Combined with exam
Lenses Single vision, lined bifocal and lined trifocal lenses
Polycarbonate lenses for dependent children
Every 12 months Combined with exam
Lens Options Standard progressive lenses
Premium progressive lenses
Custom progressive lenses
Average savings of 20-25% on other lens enhancements
Every 12 months Contacts (in lieu
of glasses) $150 allowance for contacts; copay does not apply
Contact lens exam (fitting and evaluation)
Every 12 months Up to $60
Diabetic Eyecare
Plus Program Services related to diabetic eye disease, glaucoma and age-related
macular degeneration (AMD). Retinal screening for eligible
members with diabetes. Limitations and coordination with medical
coverage may apply. Ask your VSP doctor for details. Diabetic Eyecare Plus
Copay: $20
Covered
$95-$105
$150-$175
Extra Savings and Discounts
Glasses and
Sunglasses 20% savings on additional glasses and sunglasses, including lens
enhancements from any VSP doctor within 12 months of your last
WellVision Exam
Laser Vision
Correction Average 15% off the regular price of 5% of the promotional price;
discounts only available from contracted facilities
Retinal
Screening No more than a $39 copay on routine retinal screening as an
enhancement to a WellVision Exam
Out-of-Network Reimbursement — If you choose a non-VSP provider, copayments still apply and you may receive a lesser benefit and pay more
out-of-pocket expenses. VSP guarantees service from VSP Choice network doctors only.
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