Active Health Summary Plan Description
As of September 1, 2017
En Español (PDF)

10.2 Co-Payments and Schedule of Benefits

This section modified by Amendment 4. View old language.

Anthem Blue Cross and UnitedHealthcare Plan Participants
Benefit Frequency
(Based on service year)
Co-payment Coverage from
a VSP doctor
Out-of-Network
Reimbursement
Exam 12 months $5 Covered in full after the co-payment. Up to $45 allowance
Prescription Eyewear  - If you choose contact lenses you will be eligible for frame 12 months from the date the contact lenses were obtained.
Lenses 12 months $10 (lenses and/or frame) Single vision, lined bifocal and lined trifocal lenses are covered in full after the co-payment. Single vision up to $45 allowance. Lined bifocal up to $65 allowance. Lined trifocal up to $85 allowance
Frame
as provided by VSP
24 months $10 (lenses and/or frame) Covered up to $150 allowance Up to $47 allowance
Contact Lenses* 12 months   Covered in full for medically necessary allowance, $130 allowance for Elective
Contact lenses
Up to $210 allowance for medically necessary and $105 for Elective Contact lenses

*Your allowance applies to the cost of your contact lens exam and your contact lenses. You'll receive a 15 percent savings off the cost of your contact lens exam from a VSP doctor. Your contact lens exam is in addition to your routine eye exam to check for eye health risks associated with improper wearing or fitting of contacts. You may get regular glasses (frames and lenses) twelve months after you get contact lenses.

Kaiser Vision Plan
Vision Benefit Co-pay/ Allowance
Eye refraction exams to determine the need for vision correction and to provide a prescription for eyeglasses $5 per visit
Regular plastic eyeglass lenses every 24 months $150 Allowance*
An eyeglass frame every 24 months
Medically necessary contact lenses No charge

*An allowance is the total expenses of an item that is covered. If the cost of the item you select exceeds the allowance, you must pay the difference.

Anthem Blue Cross and UnitedHealthcare Plan Participants
Benefit Frequency
(Based on service year)
Co-payment Coverage from
a VSP doctor
Out-of-Network
Reimbursement
Exam 12 months $5 Covered in full after the co-payment. Up to $45 allowance
Prescription Eyewear  - If you choose contact lenses you will be eligible for frame 12 months from the date the contact lenses were obtained.
Lenses 12 months $10 (lenses and/or frame) Single vision, lined bifocal and lined trifocal lenses are covered in full after the co-payment. Single vision up to $45 allowance. Lined bifocal up to $65 allowance. Lined trifocal up to $85 allowance
Frame
as provided by VSP
24 months $10 (lenses and/or frame) Covered up to $150 allowance Up to $47 allowance
Contact Lenses* 12 months   Covered in full for medically necessary allowance, $130 allowance for Elective
Contact lenses
Up to $210 allowance for medically necessary and $105 for Elective Contact lenses

*Your allowance applies to the cost of your contact lens exam and your contact lenses. You'll receive a 15 percent savings off the cost of your contact lens exam from a VSP doctor. Your contact lens exam is in addition to your routine eye exam to check for eye health risks associated with improper wearing or fitting of contacts. You may get regular glasses (frames and lenses) twelve months after you get contact lenses.

Kaiser Vision Plan
Vision Benefit Co-pay/ Allowance
Eye refraction exams to determine the need for vision correction and to provide a prescription for eyeglasses $5 per visit
Regular plastic eyeglass lenses every 24 months $100 Allowance*
An eyeglass frame every 24 months
Medically necessary contact lenses No charge

*An allowance is the total expenses of an item that is covered. If the cost of the item you select exceeds the allowance, you must pay the difference.