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ViewPointe®

Focus®
  EyeMed Access Network Out of Network   VSP Network Out of Network
Deductible $10 Exam
$25 Eye Glass Lenses


 No Deductible Deductible $10 Exam
$25 Eye Glass Lenses
(Deductible applies to a complete pair of glasses or to frames, whichever is selected)
 $10 Exam
$25 Eye Glass Lenses
(Deductible applies to a complete pair of glasses or to frames, whichever is selected)
Annual Eye Exam
(1 in 12 months)		 Covered in full Up to $35 Annual Eye Exam
(1 in 12 months)		 Covered in full Up to $52
Lenses (per pair)
(1 in 12 months)		     Lenses (per pair)
(1 in 12 months)		    
Single Covered in full Up to $25 Single Covered in full Up to $30
Bifocal Covered in full Up to $40 Bifocal Covered in full Up to $50
Trifocal Covered in full Up to $55 Trifocal Covered in full Up to $65
Lenticular 20% discount No benefit Lenticular Covered in full Up to $100
Progressive See lens options N/A Progressive See lens options N/A
Contacts     Contacts    
Fit & Follow Up Exams Standard: Member cost up to $40
Premium:  10% off of retail		 No Benefit Fit & Follow Up Exams 15% discount
See Additional Focus Features		 No Benefit
Elective Up to $115 Up to $100 Elective Up to $115 Up to $105
Medically Necessary Covered in full Up to $200 Medically Necessary Covered in full Up to $210
Frames
(1 in 24 months)		 $110 Up to $45 Frames
(1 in 24 months)		 $100
(The Costco allowance will be the wholesale equivalent)		 Up to $70

ViewPointe® - Lens Options
(member cost) *Lens Option member costs vary by prescription and option chosen.

ViewPointe® - Lens Options
(member cost) *Lens Option member costs vary by prescription and option chosen.
  EyeMed Access Network Out of Network   VSP Network Out of Network
Progressive Lenses Standard: $65 + lens deductible
Premium: lens cost - 20% discount - $120 allowance + Standard Progressive cost		 No Benefit Progressive Lenses Up to provider's contracted fee for Lined Bifocal Lenses. The patient is responsible for the difference between the base lens and the Progressive Lens charge. Up to Lined Bifocal allowance
Standard Polycarbonate $40 No Benefit Standard Polycarbonate Covered in full for dependent children
$33 adults		 No Benefit
Scratch Resistant Coating $15 No Benefit Scratch Resistant Coating $17 - $33 No Benefit
Anti-Reflective Coating $45 No Benefit Anti-Reflective Coating $43 - $85 No Benefit
Ultraviolet Coating $15 No Benefit Ultraviolet Coating $16 No Benefit
Lasik or PRK Average discount of 15% off retail price or 5% off promotional price at US Laser Network participating providers. N/A Lasik or PRK N/A N/A

Additional ViewPointe® Features

(In-Network Only)

Discounts: 15% discount on the remaining balance in excess of the conventional contact lens allowance. 20% discount on the remaining balance in excess of the frame allowance. 20% discount on items not covered by the plan at network providers, which may not be combined with any other discounts or promotional offers. This discount does not apply to EyeMed Provider's professional services, or contact lenses.

Lens Options (Member Cost): $15 - Tint (Solid & Gradient).

Secondary Purchase Plan: Members receive a % discount on a complete pair of glasses once the funded benefit has been exhausted. Members receive a 15% discount off the retail price on conventional contact lenses once the funded benefit has been exhausted. Discount applies to materials only.

Contact Lens Replacement by Mail Program: After exhausting the contact lens benefit, replacement lenses may be obtained at significant discounts online. Visit EyeMedvisioncare.com for details.

Additional Focus® Features

(In-Network Only)

Contact Lenses Elective: Allowance can be applied to disposables, but the dollar amount must be used all at once (provider will order 3 or 6 month supply). Applies when contacts are chosen in lieu of glasses.

Lens Options (Member Cost):

  • $15 - Solid Plastic Dye (Except Pink I & II)
  • $17 - Plastic Gradient Dye
  • $31-$82 - Photochromatic Lenses (Glass & Plastic)
  • Lens Option member cost vary by prescription and option chosen.

Additional Glasses: 20% off additional complete pairs of prescription glasses and/or prescription sunglasses (Based on applicable laws, reduced costs may vary by doctor location.)

Frame Discount: VSP offers 20% off any amount above the retail allowance. (Based on applicable laws, reduced costs may vary by doctor location.)

Laser VisionCareSM: VSP offers an average discount of 15% off or 5% off of promotional offer for LASIK, Custom LASIK and PRK. The maximum out-of-pocket per eye for members is $1,800 for LASIK and $2,300 for custom LASIK using Wavefront technology, and $1,500 for PRK. In order to receive the benefit, a VSP provider must coordinate the procedure.

Low Vision: With prior authorization, 75% of approved amount (up to $1,000) is covered every two years.

Covered Expenses will not include and no benefits will be payable for expenses incurred for:

Limitations for EyeMed Plan
  1. Vision examinations more than the frequency as indicated on the plan summary page.
  2. Lenses more than the frequency as indicated on the plan summary page.
  3. Frames more than the frequency as indicated on the plan summary page.
  4. Contact lenses more than once in any 12 month period. When chosen, contact lenses shall be in lieu of any other lenses benefit during the 12 month period. When eyeglass lenses are chosen, expenses for contact lenses are not Covered Expenses during the 12 month period
  5. Contacts limited to the amount shown on the plan summary page unless they are medically necessary. Contact lenses are defined as medically necessary if the individual is diagnosed with one of the following conditions:
    • keratoconus where the patient is not correctable to 20/30 in either or both eyes using standard spectacle lenses.
    • high Ametropia exceeding -12 D or +9 D in spherical equivalent.
    • anisometropia of 3 D or more.
    • patients whose vision can be corrected two (2) lines of improvement on the visual acuity chart when compared to best corrected standard spectacle lenses.
      If the member is diagnosed with a medically necessary condition, the Provider will submit a request for pre-authorization to EyeMed. The Medical Director reviews all requests for medically necessary contact lenses. If approved, the member will be covered for medically necessary contact lenses up to the plan allowance.
      Such payment is limited to once in a 12 month period and is in lieu of lens benefits under this proposal.
  6. Orthoptic or eye care training or any associated testing.
  7. Plano non-prescription lenses and non-prescription sunglasses (except for 20% discount).
  8. Two pair of glasses in lieu of biofocals. (Does not apply to Secondary Discounts).
  9. Lenses and frames which are lost or broken, except at the normal intervals when services are otherwise available.
  10. Medical and/or surgical treatment of the eye, eyes, or supporting structures.
  11. Services for which a claim is filled more than 1 year after completion of the service.
  12. For any procedure not listed on the Schedule of Eye Care Services.
    13.

This plan has the following limitation: (VSP Plan)

Some brands of spectacle frames may be unavailable at all locations for purchase as Covered Expenses, or may be subject to additional out-of-pocket expenses. Members may obtain details regarding frame brand availability from their treating provider or by calling VSP's Customer Care Division at (800) 877-7195

This plan does not cover: (VSP Plan)

  1. More than one eye exam in the frequency as indicated on the plan summary page.
  2. More than one pair of lenses in the frequency as indicated on the plan summary page.
  3. More than one set of frames in the frequency as indicated on the plan summary page.
  4. Services and/or materials not specifically included in the Schedule as covered Plan Benefits.
  5. Plano lenses (lenses with refractive correction of less than plus or minus .50 diopter) except as specifically allowed in the frames benefit section of the Plan Benefits.
  6. Services or materials that are cosmetic, including Plano contact lenses to change eye color and artistically painted Contact Lenses.
  7. Two pairs of glasses in lieu of Biofocals.
  8. Replacement of Spectacle Lenses, Frames and/or contact lenses furnished under this plan that are lost or damaged, except at the normal intervals when services are otherwise available.
  9. Orthoptics or vision training and any associated supplemental testing.
  10. Medical or surgical treatment of the eyes.
  11. Contact lens modifications, polishing or cleaning.
  12. The refitting of Contact Lenses after the initial 90-day filing period.
  13. Contact Lens insurance policies or service contracts.
  14. Additional office visits associated with contact lens pathology.
  15. Local, state and/or federal taxes, except where law requires us to pay.
  16. Membership fees for any retail center in which an Affiliate or Open Access provider office may be located. Covered persons may be required to purchase a membership in such entities as a condition of accessing Plan Benefits.

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