Active Health Summary Plan Description
As of July 1, 2022
En Español (PDF)

9.2 Co-Payments and Schedule of Benefits

This section modified by Amendment 1. View old language.

Anthem Blue Cross and UnitedHealthcare Plan Participants
Benefit	Frequency (Based on service year)	Co-payment	Coverage from a VSP doctor	Out-of-Network Reimbursement
Exam	12 months	$5	Covered in full after the co-payment.	Up to $45 allowance
Prescription Eyewear and VSP LightCare1â€“ If you choose contact lenses you will be eligible for frame 12 months from the date the contact lenses were obtained.
Lenses	12 months	$10 (lenses and/or frame)	Single vision, lined bifocal and lined trifocal lenses are covered in full after the co-payment.	Single vision up to $45 allowance. Lined bifocal up to $65 allowance. Lined trifocal up to $85 allowance
Frame as provided by VSP	24 months	$10 (lenses and/or frame)	Covered up to $180 allowance	Up to $47 allowance
Contact Lenses2	12 months		Covered in full for medically necessary allowance, $150 allowance for Elective Contact lenses	Up to $210 allowance for medically necessary and $105 for Elective Contact lenses

VSP LightCare benefit allows participants to use the frame allowance towards non-prescription sunglasses or non-prescription blue light filtering glasses .
Your allowance applies to the cost of your contact lens exam and your contact lenses. You'll receive a 15 percent savings off the cost of your contact lens exam from a VSP doctor. Your contact lens exam is in addition to your routine eye exam to check for eye health risks associated with improper wearing or fitting of contacts. You may get regular glasses (frames and lenses) twelve months after you get contact lenses.

Kaiser Vision Plan
Vision Benefit	Co-pay/ Allowance
Eye refraction exams to determine the need for vision correction and to provide a prescription for eyeglasses	$5 per visit
Regular plastic eyeglass lenses every 24 months	$150 Allowance*
An eyeglass frame every 24 months	$150 Allowance*
Medically necessary contact lenses	No charge

*An allowance is the total expenses of an item that is covered. If the cost of the item you select exceeds the allowance, you must pay the difference.

Anthem Blue Cross and UnitedHealthcare Plan Participants
Benefit	Frequency *(Based on service year)*	Co-payment	Coverage from a VSP doctor	Out-of-Network Reimbursement
Exam	12 months	$5	Covered in full after the co-payment.	Up to $45 allowance
Prescription Eyewear – If you choose contact lenses you will be eligible for frame 12 months from the date the contact lenses were obtained.
Lenses	12 months	$10 (lenses and/or frame)	Single vision, lined bifocal and lined trifocal lenses are covered in full after the co-payment.	Single vision up to $45 allowance Lined bifocal up to $65 allowance Lined trifocal up to $85 allowance
Frame as provided by VSP	24 months	$10 (lenses and/or frame)	Covered up to $150 allowance	Up to $47 allowance
Contact Lenses*	12 months		Covered up to $130 allowance	Up to $210 allowance for medically necessary and $105 allowance for elective contact lenses
Your allowance applies to the cost of your contact lens exam and your contact lenses. You’ll receive a 15 percent savings off the cost of your contact lens exam from a VSP doctor. Your contact lens exam is in addition to your routine eye exam to check for eye health risks associated with improper wearing or fitting of contacts. You may get regular glasses (frames and lenses) 12 months after you get contact lenses.*

Kaiser Permanente Vision Plan
Vision Benefit	Co-pay/Allowance
Eye refraction exams to determine the need for vision correction and to provide a prescription for eyeglasses	$5 per visit
Regular plastic eyeglass lenses every 24 months	$150 Allowance*
An eyeglass frame every 24 months	$150 Allowance*
Medically necessary contact lenses	No charge
*An allowance is the total expenses of an item that is covered. If the cost of the item you select exceeds the allowance, you must pay the difference

New Participant Portal

Active Health Summary Plan Description
As of July 1, 2022
En Español (PDF)

9.2 Co-Payments and Schedule of Benefits

New Participant Portal

New Participant Portal

Active Health Summary Plan DescriptionAs of July 1, 2022En Español (PDF)

9.2 Co-Payments and Schedule of Benefits

New Participant Portal

Active Health Summary Plan Description
As of July 1, 2022
En Español (PDF)