| Benefit |
In-Network |
Out-of-network |
| Deductible |
$10 for exams
$25 for materials |
$10 for exams
$25 for materials
|
| Annual Eye Exam |
100% |
up to $45 |
| Single Vision Lens |
100% |
up to $30 |
| Std. polycarbonate |
100% for dependent children |
No Coverage |
| Bifocal |
100% |
Up to $50 |
| Trifocal |
100% |
up to $65 |
| Frames |
$130 (Costco allowance is
the wholesale equivalent) |
up to $70 |
| Contacts |
$130 |
up to 105 |
| Vision benefits are available every 12 months |
| Lens Options (member cost) |
| Option |
VSP Choice Network + Affiliates
(Other than Costco) |
Out of Network |
| Progressive Lenses |
Up to provider's contracted fee for Lined Bifocal Lenses |
Up to Lined Bifocal Allowance |
| Std. Polycarbonate |
Covered in full for dependent children/ $33 adults |
No Benefit |
| Solid Plastic Dye |
$15 (except Pink I & II) |
No Benefit |
| Plastic Gradient Dye |
$17 |
No Benefit |
| Photochromatic Lenses (Glass and Plastic |
$31-$82 |
No Benefit |
| Scratch Resistant Coating |
$17-$33 |
No Benefit |
| Anti-Reflective Coating |
$43-$85 |
No Benefit |
| Ultraviolet Coating |
$16 |
No Benefit
|
|
