Active Health Plan Benefit Tabs™

This is a summary of benefits and not a substitute for the Southern California IBEW-NECA Health Plan Summary Plan Description, and to the extent it differs from the SPD, the terms of the SPD will govern.


VSP
 

Vision is covered by Vision Service Plan (VSP) for all participants in the Anthem Blue Cross and UnitedHealthcare. Kaiser participants get all vision services, except prescription safety glasses, through Kaiser.


Getting Services
 
  1. Choose a VSP doctor at vsp.com or call 800-877-7195.
  2. Make an appointment and tell the doctor you are a VSP member.
Benefit
 
Benefit
Your Copayment
Your Coverage
Vision Exam - 1 every 12 months
$5
VSP Network Provider
Non-VSP Provider
(Out-of-Network reimbursement amounts)
Up to $45
Lenses - 1 pair every 12 months $10 (lenses and/or frame) Single vision, lined bifocal and lined trifocal lenses are covered. Single vision up to $45 allowance.
Lined bifocal up to $65 allowance.
Lined trifocal up to $85 allowance.
Frames - 1 frame every 24 months $10 (lenses and/or frame)
$150 Allowance
Up to $47
Contact Lenses $0
$130
Up to $105
Safety Glasses - for eligible Participants in Anthem Blue Cross and UnitedHealthcare Plans
Note: This benefit covers participants only - not dependents, and the same maximum allowed amounts apply as shown above.
 
Benefit Copayment
Exam - 1 every 12 months $5
There will not be a separate exam or copayment charge if the safety glass exam is conducted at the time of the annual exam.
Lenses - 1 every 12 months $10 (lenses and/or frame)
Frames - 1 every 24 months $10 (lenses and/or frame)
Safety Glasses - for eligible Participants in the Kaiser Plan
Note: This benefit is for participants only - not dependents.
 
Benefit   Copayment
Exam - 1 every 12 months $25
Lenses - 1 every 12 months $10 (lenses and/or frames)
Frames - 1 every 24 months $10 (lenses and/or frames)
Out-of-Network Reimbursement Amounts
 
Exam - Up to $45
Lenses

Single Vision - Up to $55
Bifocal - Up to $75
Trifocal - Up to $87

Frame - Up to $30
Additional Information
 

Customer Service Phone Number: 1-800-877-7195
Website: www.vsp.com

Evidence of Coverage