Page 19 - 2015 Advia CU Benefits & Notices
P. 19
Advia CU - MI 2015
Vision Coverage (Buy Up Option - VOLUNTARY) 12/12/12
Blue Vision benefits are provided by Vision Service Plan (VSP), the largest provider of vision care in the
nation. VSP is an independent company providing vision benefit services for Blues members. To find a
VSP doctor call 1.800.877.7195 and visit www.vsp.com .
NOTE: Members may choose between prescription glasses (lenses and frame) or contact lenses, but
not both.
Member’s Responsibilities (copays) VSP Network Provider Non-VSP Network Provider
Eye Exam
Prescription glasses (frame and/or lenses) $10 copay Reimbursed up to $50
Medically necessary contact lenses A combined $25 copay Reimbursement Varies
Eye Exam $10 copay Reimbursed up to $210
Complete eye exam by an ophthalmologist or
optometrist. The exam includes refraction, $10 copay Reimbursement up to $50 less $10 copay
glaucoma testing and other tests necessary to (member responsible for any difference)
determine the overall visual health of the patient
Lenses and Frames One eye exam in any period of 12 consecutive months
Standard Lenses (must not exceed 60 mm in
diameter) prescribed and dispensed by an $25 copay (one copay applies to both Reimbursement vary up to $125 less $25
ophthalmologist or optometrist. Lenses may be lenses and frames) Copay (member responsible for any
molded or ground, glass or plastic. Also covers difference)
prism, slab-off prism and special base curve
lenses when medically necessary. One pair of lenses, with or without frames, in any period of 12 consecutive months
NOTE: Discounts on additional prescription
glasses and savings on lens extras when obtained $150 allowance that is applied toward
from a VSP doctor
frames (member responsible for any cost Reimbursement up to $45 less $25 copay
Standard Frames
NOTE: All VSP network doctor locations are exceeding the allowance) less $25 copay (member is responsible for any
required to stock at least 100 different frames
with the frame allowance. (one copay applies to both lenses and difference)
Lenses Enhancements frames)
Progressive Lenses
Photochromic Lenses (Plastic) One frame in any period of 12 consecutive months
Contact Lenses
Included Not Reimbursable
Medically necessary contact lenses (requires prior Included Not Reimbursable
authorization approval from VSP and must meet
criteria of medically necessary) Reimbursement up to $210 less $25
Elective contact lenses that improve vision $25 copay copay (member is responsible for any
(prescribed, but do not meet criteria of medically
necessary) difference)
One pair on contact lenses in any period of 12 consecutive months
$150 allowance that is applied toward $105 allowance that is applied toward
contact lens exam (fitting and materials) contact lens exam (fitting and materials)
and the contact lenses (member is and the contact lenses (member is
responsible for any cost exceeding the responsible for any cost exceeding the
allowance) allowance)
One frame in any period of 12 consecutive months
Salus Group© Copyright 2014 Page | 19
Vision Coverage (Buy Up Option - VOLUNTARY) 12/12/12
Blue Vision benefits are provided by Vision Service Plan (VSP), the largest provider of vision care in the
nation. VSP is an independent company providing vision benefit services for Blues members. To find a
VSP doctor call 1.800.877.7195 and visit www.vsp.com .
NOTE: Members may choose between prescription glasses (lenses and frame) or contact lenses, but
not both.
Member’s Responsibilities (copays) VSP Network Provider Non-VSP Network Provider
Eye Exam
Prescription glasses (frame and/or lenses) $10 copay Reimbursed up to $50
Medically necessary contact lenses A combined $25 copay Reimbursement Varies
Eye Exam $10 copay Reimbursed up to $210
Complete eye exam by an ophthalmologist or
optometrist. The exam includes refraction, $10 copay Reimbursement up to $50 less $10 copay
glaucoma testing and other tests necessary to (member responsible for any difference)
determine the overall visual health of the patient
Lenses and Frames One eye exam in any period of 12 consecutive months
Standard Lenses (must not exceed 60 mm in
diameter) prescribed and dispensed by an $25 copay (one copay applies to both Reimbursement vary up to $125 less $25
ophthalmologist or optometrist. Lenses may be lenses and frames) Copay (member responsible for any
molded or ground, glass or plastic. Also covers difference)
prism, slab-off prism and special base curve
lenses when medically necessary. One pair of lenses, with or without frames, in any period of 12 consecutive months
NOTE: Discounts on additional prescription
glasses and savings on lens extras when obtained $150 allowance that is applied toward
from a VSP doctor
frames (member responsible for any cost Reimbursement up to $45 less $25 copay
Standard Frames
NOTE: All VSP network doctor locations are exceeding the allowance) less $25 copay (member is responsible for any
required to stock at least 100 different frames
with the frame allowance. (one copay applies to both lenses and difference)
Lenses Enhancements frames)
Progressive Lenses
Photochromic Lenses (Plastic) One frame in any period of 12 consecutive months
Contact Lenses
Included Not Reimbursable
Medically necessary contact lenses (requires prior Included Not Reimbursable
authorization approval from VSP and must meet
criteria of medically necessary) Reimbursement up to $210 less $25
Elective contact lenses that improve vision $25 copay copay (member is responsible for any
(prescribed, but do not meet criteria of medically
necessary) difference)
One pair on contact lenses in any period of 12 consecutive months
$150 allowance that is applied toward $105 allowance that is applied toward
contact lens exam (fitting and materials) contact lens exam (fitting and materials)
and the contact lenses (member is and the contact lenses (member is
responsible for any cost exceeding the responsible for any cost exceeding the
allowance) allowance)
One frame in any period of 12 consecutive months
Salus Group© Copyright 2014 Page | 19
