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New Participant Portal
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Register for New Participant PortalRetiree Health Summary Plan Description
As of February 1, 2018
En Español (PDF)
8.4 Vision Co-Payments and Schedule of Benefits
This section modified by Amendment 6. View old language.
| UnitedHealthcare Plan Participants | ||||
|---|---|---|---|---|
| Benefit | Frequency (Based on service year) | Copayment | Coverage from a VSP Doctor | Out-of-Network Reimbursement |
| Exam | 12 months | $5 | Covered in full after the copayment. | 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 copayment. | 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 in full for medically necessary allowance, $130 allowance for Elective Contact lenses | Up to $210 allowance for medically necessary and $105 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) 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 frames every 24 months | |
| 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 and VSP LightCare1 — 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 |
|
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.