Vision Coverage Chart

Benefits

VSP Preferred Provider

Out-of-Network

Benefit Frequency
Eye Exam
Lenses
Frames
Contact lenses (in lieu of lenses and frames)

Every 12 months
Every 12 months
Every 24 months
Every 12 months
Eye Exam $0 Reimbursed up to $45
Lenses
Single vision
Bifocal
Trifocal


$25 copay

Reimbursed up to $40
Reimbursed up to $60
Reimbursed up to $80
Frames $175 allowance Reimbursed up to $70
Contacts*
Contact lens exam
Contact lenses

$60 copay
$175 allowance

Reimbursed up to $105 for exam and lenses



*Contacts are in lieu of lenses and frames.