Medically Necessary Lenses

2021 and 2022 Plan Year Information

VSP Option AVSP Option B
Note

The figures in the chart below reflect what the Plan pays, with the exception of deductibles and out-of-pocket maximums, which employees pay.

Medically Necessary Contact Lenses with VSP Approval

In-Network:
100% after $20 copay for lenses once every calendar year

Out-of-Network:
Up to $210 allowance after $20 copay

In-Network:
100% after $20 copay for exam and $20 copay for lenses once every two years

Out-of-Network:
Up to $210 allowance after $20 copay

Notes About Lenses and Frames

The total copay for lenses generally applies to both eyeglass lenses and/or frames. You may select from a variety of optional lens types, as outlined in the Health Benefits and Insurance SPD.

Lenses are considered medically necessary for certain eye conditions that prohibit the use of glasses, including aphakia, anisometropia, high ametropia, nystagmus and keratoconus.

If you purchase frames from Costco, the frame allowance is $135 for VSP Option A and $80 for VSP Option B.

Finding a VSP Provider

Employees and their covered dependents enrolled in the vision plan may receive services and supplies from the vision care provider of their choice. However, they will pay more when they use an out-of-network provider. Find a list of in-network providers on the VSP website.