Vision Plan Chart

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Feature	In-Network Basic Plan	In-Network Easy Options Plan	Out-Of-Network
Examination
Vision exam (one per calendar year)	100% after $25 exam copay¹	100% after $25 exam copay¹	Reimbursed up to $50 after $25 exam copay
Routine retinal screening	Up to $39 copay	Up to $39 copay	No discount available
Essential medical eyecare	100% after $20 copay	100% after $20 copay	N/A
Eyeglass Lenses (One Pair per plan year in Lieu of Contact Lenses)
Single vision	100% after $25 materials copay¹	100% after $25 materials copay¹	Reimbursed up to $50 after $25 materials copay
Lined bifocal	100% after $25 materials copay¹	100% after $25 materials copay¹	Reimbursed up to $75 after $25 materials copay
Lined trifocal	100% after $25 materials copay¹	100% after $25 materials copay¹	Reimbursed up to $100 after $25 materials copay
Lined lenticular	100% after $25 materials copay¹	100% after $25 materials copay¹	Reimbursed up to $125 after $25 materials copay
VSP LightCare	100% after $25 materials copay¹	100% after $25 materials copay¹	Reimbursed up to $70 after $25 materials copay
CONTACT LENSES (ONCE PER PLAN YEAR IN LIEU OF EYEGLASS LENSES AND FRAMES)²
Medically necessary³	100% after $25 materials copay¹	100% after $25 materials copay¹	Reimbursed up to $210 after $25 materials copay
Elective⁴	Covered up to $180	Covered up to $250 in lieu of glasses	Reimbursed up to $120
Contact lens exam (fitting and evaluation)	Up to $60 copay	Up to $60 copay	No discount available
FRAMES (ONCE PER PLAN YEAR IN LIEU OF CONTACT LENSES)²
Frames⁵	100% after $25 materials copay¹ up to $180	Covered up to $250 frame allowance OR Covered up to $180 with choice of anti- reflective coating or progressive lenses or photochromic lenses	Reimbursed up to $70 after $25 materials copay
COSMETIC OPTIONS
Includes blended lenses, oversize lenses, tinted lenses, lens coatings, UV protected lenses and other lens options	Available at discount prices	Available at discount prices	No discount available
Progressive lenses	Standard: 100% Premium: 100% after $80-$90 copay Custom: 100% after $120-$160 copay	Standard: 100% Premium: 100% after $80-$90 copay Custom: 100% after $120-$160 copay	No discount available
DIABETIC EYECARE
Services related to diabetic eye disease, glaucoma and age-related macular degeneration (AMD). Retinal screening for eligible members with diabetes.	$20	$20	No discount available
LASER VISION CORRECTION⁶
Photorefractive Keratectomy (PRK) or LASIK surgery	Discounted services available	Discounted services available	No discount available

¹ There is a limit of one in-network copay per plan year—either the exam copay or the materials copay. The materials copay applies to eyeglass lenses, frames and medically necessary contact lenses.
² Contact lens coverage is always in lieu of lenses and frames. Frame coverage is always in lieu of contact lens coverage. If you purchase contact lenses in a plan year, you are not eligible for frame coverage that plan year.
³ Medically necessary contact lenses must be approved by VSP. They are covered if required for certain medical conditions that prevent you from wearing eyeglasses.
⁴ The contact lens allowance is applied to the contact lenses. There is a 15% discount off of the cost of your contact lens professional services (fitting and evaluation) when obtained from a VSP doctor, which means the $180 allowance goes further in-network. See VSP for special offers and rebates.
⁵ If you choose a frame valued at more than $180, you will receive a 20% discount on the amount over your allowance. When you purchase frames and lenses together in-network, only one copay applies.
NOTE: Walmart and Costco’s frame allowance is $100, which is lower than the frame allowance described in the chart. The frame allowance increases $20 with featured frame brands. Go to www.vsp.com/offers.
⁶ Laser vision correction is available through contracted laser centers. Program availability may vary based on location.

Vision Plan Chart

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