VIPA 100
Plan
Dual Choice Illustration
Benefit Specification
|
Service/Material
|
Participating Provider
|
Non-Participating Provider
|
|
Vision Examination* |
Paid in Full
|
Up to: $35.00 Retail Value
|
|
Frame
|
Up to: $100.00 Retail Value
|
Up to: $50.00 Retail Value
|
|
Lenses
(Clear, Standard, Glass or Plastic)
|
||
|
Single Vision (Pr)
|
Paid in Full
|
Up to: $25.00 Retail Value
|
|
Bifocal (Pr)
|
Paid in Full
|
Up to: $40.00 Retail Value
|
|
Trifocal (Pr)
|
Paid in Full
|
Up to: $45.00 Retail Value
|
|
Contact Lenses**(including
related diagnostic, fitting and evaluation services)
|
||
|
Elective
|
Up to: $125.00 Retail Value
|
Up to: $100.00 Retail Value
|
|
Medically Required
|
Paid in Full
|
Up to: $150.00 Retail Value
|
Frequency Options
|
Platinum
|
Gold
|
Silver
|
Bronze
|
|
|
Examination
|
12 Months
|
12 Months
|
12 Months
|
24 Months
|
|
Frames
|
12 Months
|
24 Months
|
24 Months
|
24 Months
|
|
Lenses
|
12 Months
|
12 Months
|
12 Months
|
24 Months
|
|
Contacts
|
12 Months
|
12 Months
|
24 Months
|
24 Months
|
* Vision examination is not a covered
benefit under the Materials Only Plan.
** Contact lens benefit is in lieu of the frame and eyeglass lens benefit.
Contact lens fitting fees and related services are included in the CL
benefit, not vision exam benefit.
