(Kaiser Permanente Plan Participants Must Use Kaiser Permanente Plan Facilities; Benefits Outlined in Evidence of Coverage Brochure)
The Plan offers two separate Vision Plans. One through VSP and the other through Safeguard. The summary of benefits is listed below. Once you have enrolled in a vision plan, you and all of your enrolled Dependents1 must remain in that Vision Plan until the next Open Enrollment. If you require further clarification of vision benefits, contact VSP at (800) 877-7195 (or visit www.vsp.com), or Safeguard at (800) 880-1800 (or visit www.safeguard.net).
BENEFIT VISION SERVICE PLAN SAFEGUARD
Examinations Once each 12 months Once each 12 months
Spectacle Lenses One each 12 months if prescription has changed
One each 12 months if prescription has changed
Frames Once each 24 months Once each 24 months
Medically Necessary Contacts (in lieu of other benefits)
Once each 12 months Once each 24 months
Elective Contacts (in lieu of other benefits)
Once each 12 months Once each 24 months
Sunglasses Paid accordingly in lieu of regular glasses
Paid accordingly in lieu of regular glasses
Copayment $5 total copay, plus any amount over allowance or for cosmetic options.
Medically necessary contacts are covered in full, less the copay.
Cosmetic contacts are covered up to
$105.
$5 exam plus any amount over allowance or for cosmetic options.
Medically necessary contacts are covered in full, less the co-pay.
Cosmetic contacts are covered up to
$50 exam and $100 materials.
How to Obtain Services (Contracted providers only)
(800) 877-7195.
The participating Doctor will obtain authorization.
(800) 880-1800.
The participating Doctor will obtain authorization.
Frame Allowance Frames of your choice every 24 months covered up to $115 plus 20%
of any out-of-pocket over $115
$35 Maximum Wholesale Allowance If you wish to purchase a frame not fully covered by the plan, you will be responsible for the difference between the allowance and the wholesale cost of the more expensive frame, plus an additional service fee.
Non-Medically Necessary Contact Lens Allowance
$105 Allowance: The allowance applies to the cost of your contacts and the contact lens exam (fitting and evaluations). Contacts are available in lieu of frames and lenses.
$120 Maximum Retail Allowance The above coverage applies to prescriptions for contact lenses that are not Medically Necessary.
(Contact lenses are offered in lieu of frames and lenses.)
BENEFIT VISION SERVICE PLAN SAFEGUARD Medically Necessary Contact Lens
Allowance
Covered in full. $250 Maximum Allowance
Participating Providers have agreed to limit their charges to a reduced amount that is 80% of their usual charge. The allowance applies to all costs associated with obtaining contact lenses. You are responsible for any charges in excess of the allowance plus any applicable Copayments. (Contact lenses are offered in lieu of frames and lenses.)
VSP LIMITATIONS AND EXCLUSIONS
This Plan is designed to cover your visual needs rather than cosmetic eyewear. You are responsible for additional costs if you choose extras, including:
1. Blended or oversized lenses;
2. Progressive multifocal lenses;
3. Photochromic or tinted lenses other than Pink 1 or 2;
4. Coated, laminated or UV protected lenses;
5. Cosmetic lenses or processes unless specifically covered on page 44; and 6. A frame that exceeds your allowance.
You are not covered for the following services or eyewear:
1. Orthoptics or vision training and supplemental training;
2. Plano lenses (non-prescription);
3. Two pairs of glasses instead of bifocals;
4. Replacement of lost or broken glasses, except at the normal intervals when services are otherwise available;
5. Medical or surgical treatment of the eyes; and
6. Corrective vision services, treatments and eyewear of an Experimental nature.
SAFEGUARD LIMITATIONS AND EXCLUSIONS
No benefits are payable under this Plan for any expenses incurred for:
1. Any procedures not specifically listed as a covered benefit in the Schedule of Benefits.
2. Services and supplies provided by a provider who is not a Participating Vision Provider, except as specifically described in the section entitled “Emergency Vision Care” in the Evidence of Coverage.
3. Charges for services and materials that the Participating Vision Provider determines to be (1) not Medically Necessary, (2) beyond the maximum material allowance for frames and contact lenses indicated in the Schedule of Benefits, or (3) non-basic, are excluded.
4. Hospital and medical charges of any kind, medical transportation, vision services rendered in a Hospital, prescriptions or medications, and medical or surgical treatment of the eyes are excluded.
5. Prescriptions from non-Participating Vision Providers.
6. Replacement due to loss, theft or destruction is excluded, except when replacement is at the regular time intervals of coverage under the vision plan.
7. Orthoptics and vision training and any associated testing, subnormal vision aids, plano (non-prescription) lenses are excluded.
8. A second pair of glasses in lieu of bifocals.
9. Services that cannot be performed because of the general health, physical, emotional, mental or behavioral limitations of the patient.
10. Services and supplies considered Experimental in nature.
11. Services and supplies rendered by a person who resides in the Member’s home, or by an immediate relative of the Member.
12. Services or supplies provided for or paid by a federal or state government agency or authority, political subdivision, or other public program.
13. Any expenses paid by any Workers’ Compensation law or act, Employers’ Liability law or by any governmental program, law or agency, except for Medicare or Medicaid.
14. Any services or materials as a condition of employment (e.g., safety glasses).
15. Charges associated with copying or transferring vision records.