Benefit |
Frequency |
Copay |
From VSP Provider |
Out-of-Network Provider |
Examination
All ages |
12 months |
$10
|
Covered in full*
|
Covered up to $25
|
Materials
Single vision Lenses
Bifocal Lenses
Trifocal Lenses
Lenticular Lenses
Progressive Lenses
Polycarbonate Lenses
Frames
|
12 months
12 months
12 months
12 months
12 months
12 months
12 months
|
$15 (for lenses and frames)
|
Covered in full*
Covered in full*
Covered in full*
Covered in full*
Covered in full*
Covered in full*
Covered in full* (up to $120.00)
|
Covered up to $25
Covered up to $35
Covered up to $52
Covered up to $62
No coverage
No coverage
Covered up to $18 |
Contact Lenses
Medically necessary
Elective |
12 months
12 months
|
$15
None |
Covered in full*
Covered to $125 |
Covered up to $210
Covered up to $125
|
EyeMed Vision Care Plan |
BENEFIT |
FREQUENCY |
CO-PAY |
FROM EYEMED PROVIDER |
OUT-OF-NETWORK PROVIDER |
Examination
All ages |
12 months |
$5
|
Covered in full* |
Covered up to $25
|
Materials
Single vision lenses
Bifocal lenses
Trifocal lenses
Lenticular lenses
Progressive Lenses
Polycarbonate Lenses
Frames
|
12 months
12 months
12 months
12 months
12 months
12 months
12 months |
N/A
|
Covered in full*
Covered in full*
Covered in full*
Covered in full*
Covered in full*
Covered in full*
Covered in full* (up to $120.00) |
Covered up to $25
Covered up to $35
Covered up to $52
Covered up to $62
No coverage
No coverage
Covered up to $18 |
Contact Lenses
Medically necessary
Elective |
12 months
12 months
|
$15
None |
Covered in full*
Covered to $125 |
Covered up to $210
Covered up to $125
|
