VSP provides full benefits for covered services and/or materials when you go to a participating provider for:

• One comprehensive examination in any 12 consecutive months
• One part of standard lenses in any 12 consecutive months
  • Standard lenses fit any frame with an eye size less than 61mm
• One standard frame in any 24 consecutive months
  • Standard frames have a maximum retail cost of $105.00 or less
• In lieu of lenses & frames: one pair of contact lenses in any 12 consecutive months
  • If contact lenses are for cosmetic or convenience purposes, the plan will pay up to $105.00 towards the cost; any remaining balance is the patient’s responsibility
  • If contact lenses are medically necessary, they are a fully-covered benefit after prior authorization is obtained:
    • Following cataract surgery
    • When visual acuity cannot be correct to 20/70 in the better eye except through the use of contacts
    • When necessitated by anisometropia or certain conditions of keratoconus

If services are rendered by a non-participating provider, the insured will receive reimbursement based upon the Schedule of Allowance. The non-participating provider or the insured can submit an itemized bill, a copy of the member’s prescriptions, and a claim form to VSP for payment.

If covered services and/or materials are provided by a non-participating provider, charges will be paid but not to exceed the following Schedule of Allowances:

**This allowance is in lieu of other eyewear.

Benefit frequencies are the same as listed under the INN benefits.

• Lenses or frames which were furnished under the plan and which have been lost, stolen, or broken will not be replaced, except when benefits are otherwise available
• Eyewear when there is no prescription change, except when benefits are otherwise available
• Lenses such as no-line (blended type), varilux (progressive), flat-top 35, executive-style, coated, oversized, hi-index, polycarbonate, beveled or faceted, will be limited to the Schedule of Allowances
• Contact lenses will be limited to the Schedule of Allowances

• Conditions covered by Workers’ Compensation
• Services which begin prior to the insured’s effective date or after benefits have terminated
• Services & supplies in connection with special procedures such as orthoptics or vision training and subnormal vision aids
• Non-prescription (plano) eyewear
• Frame cases
• Tints, other than Rose and Pink #1 and #2, except when noted
• Contact lens fitting charges
• Contact lens insurance, care kits and supplies
• Medical or surgical treatment of the eyes
• Charges for which the insured is not required to pay
• Eye examinations required by an employer as a condition of employment
• Any service or material provided by another vision plan