Agmt91 Vision Service Plan VSP - Laserfiche WebLink

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VISION SERVICE ~ CHOICE OF PROVIDERS The VSP plan provides covered persons with a dual choice. If they elect to receive vision care services from one of the VSP Panel Doctors, VSP is a PREPAID program and covered services as described herein are provided at no out-of-pocket cost (unless the plan contains a deductible). Selecting a doctor from the VSP list assures direct payment to the doctor and a guarantee of quality and cost control. SERVICES FROM NON-PANEL PROVIDER LIABILITY OF COVERED PERSONS FOR PAYMENT REIMBURSEMENT PROVISIONS When a covered person chooses to go to a non-panel provider, services may be secured from any optometrist, ophthalmologist and/or dispensing optician, and VSP becomes an indemnity plan reimbursing according to a schedule of allowances. The covered person should pay the doctor his full fee. VSP will reimburse in accordance with the following schedule. THERE IS NO ASSURANCE THAT THE SCHEDULE WILL BE SUFFICIENT TO PAY FOR THE EXAMINATION OR THE MATERIALS. AVAILABILITY OF SERVICES UNDER THIS REIMBURSEMENT SCHEDULE IS SUBJECT TO THE SAME TIME LIMITS AND DEDUCTIBLE AS THOSE DESCRIBED FOR PANEL SERVICES. SERVICES OBTAINED FROM A NON-PANEL PROVIDER ARE IN LIEU OF OBTAINING SERVICES FROM A PANEL MEMBER OF VSP. MAXIMUM REIMBURSEMENT FOR SERVICES FROM NON-PANEL PROVIDER PROFESSIONAL FEES Vision Examination, up to $ 40.00 MATERIALS PAIR Single Vision Lenses, up to $ 30.00 Bifocal Lenses, up to 50.00 Trifocal Lenses, up to 65.00 Lenticular Lenses, up to 125.00 Frame, up to 45.00 CONTACT LENSES* Necessary, up to $250.00 Elective, up to 130.00 LOW VISION See Addendum Re: Low Vision Benefits *Determination of "necessary" versus "elective" contact lenses under the non-panel reimbursement schedule will be consistent with Panel Dcctor services. Reimbursement for contact lenses is in lieu of all b~nefits, including examination and material services. -5- 4/87NP-AB -,»,,-- . ~"_^'__""--"---.._-,.,,---~._,..,.~-~..,--._- ¡