o DAS/HRD Benefits - Dental and Vision Benefits - Vision Reimbursement Schedule C

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Member Benefits and Non-Member Reimbursement Schedule

Vision Service Plan (VSP)

BENEFIT
FREQUENCY
CO-PAY
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

Lenses
12 months
12 months

Contact
$15
None		 Contact nses
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

Contact
12 months
12 months

Contact L
$15
None		 Contact enses
Covered in full*
Covered to $125

ntact Lenses
Covered up to $210 Covered up to $125

* Within plan limitations. Check with your provider. This schedule may not cover all expenses for the eye exam or materials.

Laser Vision Correction
Discounted services are available through contracted laser centers. Program availability may vary based on location and regulatory approval. Contact VSP at 800-877-7195 or EyeMed at 866-723-0514 for more information.

  
 
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