Davis Behavioral Health 2024-2025 Benefit Guide | Page 19

Administered by Vision Service Plan

Regular eye examinations can not only determine your need for corrective eyewear but also may detect general health problems in their earliest stages . Enroll in one of our vision plans to protect your eyes ! These plans may offer in-network and out-of-network benefits . However , to receive the maximum benefits from the plan you should always use participating providers . To find a provider , use the respective contact information shown in the back of this guide .

EYE EXAM

In-Network

Out-of-Network

Eyeglass Exam $ 10 copay Reimburse up to $ 45

STANDARD PLASTIC LENSES

VSP

1901 W . Parkway Blvd . Salt Lake City , UT 84119

Phone : 800.877.7195 www . vsp . com

Single Vision Covered in full after $ 25 copay Reimburse up to $ 30

Bifocal Vision Covered in full after $ 25 copay Reimburse up to $ 50

Trifocal Vision Covered in full after $ 25 copay Reimburse up to $ 65

Lenticular Covered in full after $ 25 copay Reimburse up to $ 100

LENS OPTIONS

Standard Progressive Lenses Covered in full after $ 25 copay Reimburse up to $ 50

Progressive Options Standard Anti-Reflective Polycarbonate

COATINGS

Scratch Resistant Coating

Ultra Violet Protection

Other Options

( Protection from UV , relief from digital eyestrain , and more )

FRAMES

Allowance Based on Retail Pricing

LightCare Non-prescription blue light filtering glasses or sunglasses 4 , 11

Additional pairs of glasses throughout the year

CONTACTS ( Instead of lenses and frame )

Premium : $ 95 - $ 105 copay ; Custom : $ 150 - $ 175 copay

$ 41 copay $ 31 - $ 35 copay ; $ 0 copay for children

$ 17 copay

$ 16 copay

Average savings of 30 % on all lens enhancements 1

Not applicable

Not applicable

Covered in full after $ 25 copay up to $ 150 allowance 4 Extra $ 20 allowance on Featured Frame

Brands 4 , 6 Reimburse up to $ 70

Covered-in-full after copay , up to frame allowance 4

Up to 20 % off Retail 3 , 4

Elective Covered in full up to $ 150 allowance Reimbursed up to $ 105 3 , 8

Necessary Covered in full after $ 25 copay Reimbursed up to $ 210

Fitting , and Evaluation

( Standard and Premium )

Additional pairs of glasses up to $ 60 Not applicable

20 % off unlimited additional pairs of prescription glasses and / or non-prescription sunglasses 3 , 4 , 5 Not applicable 10

* Copays for progressive lenses may vary . This is a summary of plan benefits . The actual policy will detail all plan limitations and exclusions .

Discounts — Any item listed as a discount in the benefit outline is a merchandise discount only and not an insured benefit . Providers may offer additional discounts .

1 Savings off average usual and customary pricing based on VSP claims data . 3 Based on applicable laws , benefits may vary by location . 4 Benefits may vary at retail chain locations . Costco frame allowance is $ 70 as prices already include discounts instead of those noted . Extra frame allowance on Featured Frame Brands is not available at Costco , Walmart and Sam ’ s Club . 5 30 % off applies to glasses purchased the same day as the member ' s eye exam from the same VSP doctor who provided the exam . Members also receive 20 % off unlimited additional pairs of glasses valid through any VSP network provider within 12 months of the last covered eye exam . Exceptions at retail locations may apply . 6 Reflects current promotion . Featured Frame Brands are subject to change . Available only to VSP members with applicable plan benefits through VSP network doctors and in-network locations . Not available to members whose coverage includes an additional $ 50 allowance on Featured Frame Brands . In the event of a conflict between this information and your organization ’ s contract with VSP , the terms of the contract will prevail . 8 Essential Medical Eye Care pays secondary to the member ’ s medical insurance . 10 Essential Medical Eye Care is available out-of-network in states where it ’ s required by law . 11 Pre-made and ready-to-wear glasses are covered by plan ’ s frame and lens benefit and is in lieu of prescription frame and lenses .

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