Vision Service Plan (VSP) features more than 22,000 professional vision care providers for persons covered under the Relief PPO Medical Plan. Using your VSP benefits is easy. Find a provider who is right for you, renew your benefit information and at your appointment, tell your provider you have VSP. That’s it! There are no I.D. cards or claim forms necessary.
PLAN SUMMARY
| VSP | NON-VSP | |
|---|---|---|
 EYE EXAM *Once per calendar year | $10 COPAY | Up to $45 |
| VSP | NON-VSP | |
|---|---|---|
 LENSES *Once per calendar year | 100% 100% 100% 100% $80 – $90 copay $120 – $160 copay | Up to $45 Single Vision Up to $65 Bifocal Up to $85 Trifocal Up to $85 Standard Progressive Up to $85 Premium Progressive Up to $85 Custom Progressive |
| VSP | NON-VSP | |
|---|---|---|
 FRAMES *Every other calendar year | Up to $200 | Up To $47 |
| VSP | NON-VSP | |
|---|---|---|
 CONTACT LENSES (Instead of Glasses) *Once per calendar year | Up to $160 | Up to $105 |
| VSP | NON-VSP | |
|---|---|---|
LASIK SURGERY *Once per lifetime | Up to $1500 per eye for LASIK eye surgery, custom LASIK & PRK | Up to $500 per eye for LASIK eye surgery, custom LASIK & PRK $90 OON reimbursement for exams associated with LASIK |
Essential Medical Eye Care
Essential Medical Eye Care allows you to receive additional follow-up medical eye care services from your
VSP doctor, who knows your eyes best.
WHAT’S COVERED UNDER ESSENTIAL MEDICAL EYE CARE?
- Covered-in-full retinal screening (digital imaging of the inside of the eye) for members with diabetes who do not have diabetic eye disease. These retinal photographs help your doctor establish a baseline to monitor and track changes in your eyes over time
- Additional exams and services that track and monitor diabetic eye disease progression
- Treatment for dry eye, pink eye, eye injury, and foreign body removal
- Exams and services to diagnose and monitor glaucoma and cataracts
- Tests to diagnose sudden vision changes
Vision coverage is automatically included when you enroll in the Relief PPO Medical Plan. You can choose any provider, but you’ll save money if you use a VSP network provider. If you use a non-VSP provider, you are responsible for paying the provider in full and submitting a claim to VSP for reimbursement. Take a look at the Benefits Summary for your vision benefits through VSP.
To find a vision care provider or for more information, call VSP at (800) 877-7195 or visit vsp.com.
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