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» Out-of-Network Reimbursement Form
Once every 12-months receive a WellVision Exam for Free.
Once every 12-months pay Nothing for Lenses and/or Frames.
Once every 12-months receive Single, Lined-Bifocal, Lined-Trifocal or Standard Progressive (No-Line) Lenses for Free. Or, receive Premium Progressive Lenses for an $80-$90 Co-Pay, or Custom Progressive Lenses for a $120-$160 Co-Pay.
Tints, Dyes, Photochromics & Polycarbonate Lenses are Free. Scratch-Resistance Coatings, High Index Lenses, Edge Polishing, UV Protective Coatings, Anti-Reflective Coatings and other Lens Customizations are Discounted.
Once every 12-months spend up to $150 and receive a 20% Discount for amounts over that. For additional glasses or sunglasses receive a 20% Discount.
Instead of Lenses and/or Frames, once every 12-months spend up to $150 on Contact Lenses. Additionally, once every 12-months receive a 15% Discount on a Contact Lens Fitting & Evaluation, paying a maximum of $60, without reducing the amount available for Contact Lenses.
Laser Vision Correction is Discounted. Diabetic EyeCare Plus provides follow-up medical care for Members with Type I or II Diabetes. TruHearing offers 20% Discount for Digitial Hearing Aids. Visit www.vsp.com for more details on all 3 programs.
Out-of-Network Reimbursement Form
Members can utilize out-of-network providers, but they will be required to pay the provider in full at the time of service. Members can then apply for a partial reimbursement directly from VSP. Claims must be filed within 6-months of the date of service. Members may receive the following reimbursement allowances for out-of-network services after any applicable co-pays or deductibles:
$ 50 Exam
$ 50 Single Vision Lenses
$ 75 Lined Bifocial Lenses
$100 Lined Trifocal Lenses
$125 Lenticular Lenses
$ 75 Progressive Lenses
$ 70 Frames
$105 Elective Contact Lenses
$ 5 Tints
Use Employer Sponsored rates when employees pay less than 50% of the premium
Use Voluntary (Employee Paid) rates when employees pay more than 50% of the premium
|Member & Spouse||27.24||32.48|
|Member & Child(ren)||27.74||32.98|
with Comprehensive Progressive Lens Coverage
|Member & Spouse||30.48||35.98|
|Member & Child(ren)||30.98||35.48|
with Computer VisionCare Coverage
|Member & Spouse||29.48||33.98|
|Member & Child(ren)||29.98||34.98|
with Comprehensive Progressive Lens & Computer VisionCare Coverage
|Member & Spouse||31.98||37.24|
|Member & Child(ren)||32.48||37.48|