Provider Procedural Manual - The Health Plan

PROVIDER PROCEDURAL MANUAL 2014THE HEALTH PLANVISION SERVICE BENEFITVision Examination - A complete analysis of the eyes and related structures to determine thepresence of vision problems.• Lenses - The VSP Panel Doctor will order the proper lenses. The program providesthe finest quality lenses fabricated to exacting standards. The doctor also verifies theaccuracy of the finished lenses.• Frames - The plan offers a wide selection of frames; however, if you select a framewhich costs more than the amount allowed by your plan (or a large frame thatrequires oversize lenses) there will be an additional charge.Necessary Contact lenses - Contact lenses and the necessary ophthalmic materials are coveredunder this Vision Service Plan when a VSP Panel Doctor receives prior approval for one of thefollowing conditions:a) Following cataract surgeryb) To correct extreme visual acuity problems not correctable with spectacle lensesc) To correct for significant anisometropiad) KeratoconusCosmetic (Elective) Contact Lenses - When contact lenses are chosen for reasons other than theabove, they are considered cosmetic in nature. An allowance of $100.00 will be made towardtheir cost in place of all other benefits (exam, lenses and frames) for the benefit period.I. How Often Are These Services Available?Examination - Once every 12 monthsLenses - Once every 24 monthsFrames - Once every 24 months... orContact Lenses - (In place of all other plan benefits for the benefit period).Necessary - Once every 24 monthsCosmetic - Once every 24 monthsII.How Much Do I Pay?When you obtain services from a VSP Panel Doctor, this plan covers the benefits describedherein (examination, professional services, lenses and frames).Any additional care, services and/or materials not covered by this plan may be arranged betweenyou and the doctor.Section 3 / Page 24