MCHCP Vision Benefits

Vision Service Plan Benefit Summary

Benefits	Network^**	Non-Network^**
Examinations	$20 copayment	Reimbursed up to $36
Materials^*
Single vision lenses (per pair)	$25 copayment	Reimbursed up to $28
Bifocal lenses (per pair)	$25 copayment	Reimbursed up to $45
Trifocal lenses (per pair)	$25 copayment	Reimbursed up to $56
Lenticular lenses (per pair)	$25 copayment	Reimbursed up to $80
Frames - once every 24 months*	$25 copayment ($120 retail allowance + 20% discount on any out-of-pocket costs)	Reimbursed up to $45
Polycarbonate lenses for dependent children are covered at a VSP doctor at no additional cost.
Optional items (cosmetic extras)	Not covered	Not covered
Contact Lenses and Associated Services Including Evaluation, Design and Fitting
Elective (If member prefers contacts to glasses)	$20 copayment for exam Up to $125 allowance for cost of contacts and contact lens exam (fitting and evaluation) - This exam is in addition to your vision exam to ensure proper fit of contacts 15% discount on the cost of contact lens exam (fitting and evaluation)	Reimbursed up to $36 for exam Contact lenses and fitting and evaluation exam reimbursed up to $105 allowance
Necessary^*** (If medically necessary with prior approval)	$20 copayment for exam Additional costs covered at 100%	Reimbursed up to $36 for exam Contact lenses and fitting and evaluation exam reimbursed up to $210 allowance

Receive 20% off additional prescription and non-prescription glasses and sunglasses.
Current soft contact lens wearers may qualify for a special contact lens program that includes a contact lens evaluation and initial supply of replacement lenses.
Learn more from your doctor or at www.vsp.com.

*One $25 copayment for lens and frame
** All applicable copayments apply
***Requires prior approval from vsp

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