Vision Service Plan
Vision Benefits for Blue Cross HMO and PPO plans
1-800-877-7195
Group # 12081648
Website: http://www.vsp.com
| Benefit | Frequency | Copayment (based on service year) | Coverage from a VSP doctor | Out-of-Network Reimbursement |
| Eye Care Wellness - Regular exams are essential for protecting your visual wellness. |
| Exam | 12 months | $ 20 total
(applied to exam lenses, frame, and contact lenses) | Coverage in full | Up to $45 allowance |
| Prescription Eyewear - You may choose between glasses or contacts. Remember if you choose contacts, you will not be eligible to receive glasses (lenses and frames) in the same service period. |
| Lenses | 24 months | | Single vision, lined bifocal and lined trifocal are covered in full.1 | Single vision up to $45 allowance
Lined bifocal up to $65 allowance
Lined trifocal up to $85 allowance |
| Frame | 24 months | | Covered up to $120 allowance2 | Up to $47 allowance |
| Contact Lenses - Visually Necessary | 24 months |
| Coverage in full | Up to $210 allowance |
| Contact Lenses - Elective | 24 months |
| Covered up to $120 allowance | Up to $105 allowance |
| 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 performed in addition to your routine eye exam to check for eye health risks associated with improper wearing or fitting of contacts. |
Value Added Discounts
1 Lens options, which can enhance the appearance, durability and function of your glasses, are available to you at VSP's member preferred pricing. Ask your doctor for details.
2 If you choose a frame valued at more than your allowance, you'll save 20 percent on your out-of-pocket costs for frames.
For more information, download:
- Santa Clara University VSP WellVision Coverage At a Glance (coming soon)
- Group Vision Care Plan - Evidence of Coverage and Disclosure Form (PDF)
- VSP Informative Flyers (PDF)
