VSP (Vision Service Plan) - For employees enrolled in either Non-Kaiser medical plan
BENEFITS:
- Examination - Once every 12 months
- Lenses - Once every 12 months
- Frame - Once every 24 months
COPAYMENT:
- Examination - $10.00
- Materials - $25.00
Services and Cost Comparison of VSP Participating Provider vs. a Non-Participating Provider
| Services from a VSP Participating Provider (1) | Services from a Non-Participating Provider | |
|---|---|---|
| Examination | Paid-in-Full | up to $43.00 |
| Single Vision Lenses | Paid-in-Full | up to $26.00 |
| Bifocal Lenses | Paid-in-Full | up to $43.00 |
| Trifocal Lenses | Paid-in-Full | up to $60.00 |
| Lenticular Lenses | Paid-in-Full | up to $100.00 |
| Frame (2) | up to $130.00 | up to $40.00 |
| Contact Lenses (3) | (In lieu of a complete pair of prescription glasses) | |
| Necessary | Paid-in-Full less copayment | up to $210.00 |
| Elective | up to $130.00 | up to $100.00 |
Obtaining services from a VSP Provider:
When you want to obtain vision care services, call a VSP doctor to make an appointment. For details on how you locate a VSP doctor, go to www.vsp.com or contact an SDSURF Specialist or call VSP at 800-877-7195 to request a VSP doctor listing. Make sure you identify yourself as a VSP member, and be prepared to provide the your social security number. When you seek services the VSP provider will contact VSP to verify your eligibility and plan coverage (VSP Choice), and will also obtain authorization for services and materials. If you are not currently eligible for services, the VSP doctor is responsible for communicating this to you. You may also view your eligibility and plan coverage by logging in to www.vsp.com. VSP will pay the doctor directly for covered services and materials.
Obtaining services from an out-of network provider:
Services and materials obtained from an out-of-network provider will be reimbursed up to amounts on the above schedule less any copayments. For out-of-network reimbursement, pay the entire bill when you receive services, then send your itemized receipts and full patient and member information to VSP. Claims must be submitted to VSP within six months from your date of service. Please keep a copy of the information for your records and send the originals to the following address: Vision Service Plan, Out-of-Network Provider Claims, P.O. Box 997100, Sacramento, CA 95899-7100.
ADDITIONAL BENEFITS:
Laser Vision Correction:VSP's Laser VisionCareSM program is also available to those covered under this VSP WellVisionŽ Plan. It is designed to provide members with a discount off laser surgery when obtained through VSP contracted doctors, surgeons and laser centers. This program includes the two most common laser vision correction procedures, laser-assisted in-situ keratomileusis (LASIK) and photorefractive keratectomy (PRK). Call your VSP doctor to check if he or she is participating in the program. Doctors can also be located on VSP's Web site at www.vsp.com or by calling 888-354-4434.
1 When an exam and/or materials are received from a VSP doctor, the patient will have no out-of-pocket expense other than the copayment, unless optional items are selected. Optional items include, but are not limited to, oversize lenses (61 mm or larger), coated lenses, no-line multifocal lenses, treatments for cosmetic reasons or a frame that exceeds the plan allowance. VSP doctors offer valuable savings including a 20 percent discount on non-covered pairs of prescription glasses (lenses and frame). Services must be received within 12 months from the same VSP doctor who provided your last covered eye exam. You can also save 15 percent off the cost of your contact lens exam when you receive contact lens services from VSP. (This discount does not apply to the contact lens materials).
2 Your VSP benefit provides guaranteed savings whether you choose a frame that is covered in full or one that exceeds the plan allowance. If you choose a frame valued at more than the plan's allowance, the difference you'll pay is based on VSP's low, discounted member pricing. Have your doctor help you choose the best frame for you based on your VSP coverage.
3 The allowance is in addition to the 15 percent discount on the contact lens exam. The allowance is applied to both the contact lens exam (fitting and evaluation) and the contact lenses. Any costs exceeding this allowance are the patient's responsibility. The contact lens exam is a special exam for ensuring proper fit of your contacts and evaluating your vision with the contacts. Medically necessary contact lenses must be prescribed by your doctor (as required for certain medical conditions) and approved by VSP.
PLEASE NOTE: THIS IS ONLY A SUMMARY
For Further Information, Call Vision Service Plan Customer Service (800) 877-7195 OR go to www.vsp.com