Agmt91 Vision Service Plan VSP - Laserfiche WebLink

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VISION SERVICE PIAN C. CONTACT LENSES - LIHITATIONS Necessary Contact lenses are furnished under the VSP plan when the VSP Panel Doctor secures prior approval for any of the following conditions: 1) Following cataract surg~ry 2) To correct extreme visual acuity problems that cannot be corrected with spectacle lcnsas 3) Certain conditions of Anisometropia 4) Keratoconus When the VSP Panel Doctor receives prior approval for such cases, they are fully covered by VSP and are IN LIEU OF THOSE BENEFITS DESCRIBED ON PAGE 2 OF THIS AGREEMENT UNDER "I. VISION EXAMINATION" AND "II. MATERIALS". CONTACT LENSES ONCE FURNISHED UNDER THIS PLAN AS DESCRIBED ABOVE CAN BE REPLACED ONLY WITH PRIOR AUTHORIZATION BY VSP, BUT IN NO EVENT MORE FREQUENTLY THJu~ EVERY TWELVE (12) MONTHS. Elective When covered persons choose contact lenses for reasons other chan those mentioned above, VSP will make an allowance toward their cost of $130.00 IN LIEU OF THOSE BENEFITS DESCRIBED ON PAGE 2 OF THIS AGREEMENT UNDER "I. VISION EXAMINATION" AND "II. MATERIALS". D. LOW VISION - LIMITATIONS The Low Vision benefit provides special aid for people who have severe visual problems, and who are often referred to as "partially sighted". If a covered person falls within this category, he or she will be entitled to Low Vision services and associated materials subject to the certain limitations as set forth more fully in the attached Addendum entitled "ADDITIONAL BENEFITS -- LOW VISION". The treatment plan and charges therefor must be approved in advance of the time that services are rendered. VSP Panel Doctors have the forms to submit for approval. The covered person is required to pay 25% of the cost of any approved Low Vision program. This benefit has a maximum of $1,000 (excluding co-payments) every two (2) years. Maximum includes the supplementary testing. -3- 4/87BC \ ~_.,,--,,_."-,,_.." ~~._..,- I