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CO-PAYMENT
The benefits described herein are available to each Covered Person subject
only to payment of the applicable Copayment by the Covered Person.
Copayments are required for Plan Benefits received from Member Doctors and
Non-Member Providers. Covered Persons must also follow the proper
procedures for obtaining Benefit Authorization.
There shall be a Copayment of $15.00 for the examination payable by the
Covered Person to the Member Doctor at the time services are rendered. If
materials (lenses and frames) are provided, there shall be an additional
$25.00 Copayment payable at the time the materials are ordered. However,
the Copayment for materials shall not apply to elective contact lenses.
EXCLUSIONS AND LIMITATIONS OF BENEFITS - PATIENT OPTIONS
This Policy is designed to cover visual needs rather than cosmetic
materials. When the Covered Person selects any of the following extras,
the Policy will pay the basic cost of the allowed lenses, and the Covered
Person will pay the additional costs for the options.
• Optional cosmetic processes.• Anti-reflective coating.• Color coating.•
Mirror coating.• Scratch coating.• Blended lenses.• Cosmetic lenses.•
Laminated lenses.• Oversize lenses.• Polycarbonate lenses.• Photochromic
lenses, tinted lenses except Pink #1 and Pink #2.• Progressive multifocal
lenses.• UV (ultraviolet) protected lenses.• A frame that costs more than
the Plan allowance.• Contact lenses (except as noted elsewhere herein).•
Certain limitations on low vision care.
NOT COVERED
There is no benefit for professional services or materials connected with:
• Orthoptics or vision training and any associated supplemental testing;
plano lenses (less than a ± .50 diopter power); or two pair of glasses in
lieu of bifocals; • Replacement of lenses and frames furnished under this
Policy which are lost or broken, except at the normal intervals when
services are otherwise available; • Medical or surgical treatment of the
eyes; • Corrective vision treatment of an Experimental Nature; • Costs for
services and/or materials above Plan Benefit allowances; • Services and/or
materials not indicated on this Schedule as covered Plan Benefits.
VSP MAY, AT ITS DISCRETION, WAIVE ANY OF THE POLICY LIMITATIONS IF, IN THE
OPINION OF VSP's OPTOMETRIC CONSULTANTS, IT IS NECESSARY FOR THE VISUAL
WELFARE OF THE COVERED PERSON.
See the Exhibit A: Vision Service Plan Insurance Company Schedule of
Benefits Signature Choice Plan B $15/$25 for additional information.
This is not an attempt to
describe the vision product coverage and its; contents but merely used as a
sales tool for the purpose of product illustration. The website and
its; owners cannot make recommendations as to whether any
illustrated product may meet the users' particular needs. Therefore,
the suitability of the product is the final determination of the
user of this website. The use of this website is acceptance of the
sites privacy statement. Coverage is not in effect until an
application is signed, transmitted, payment received and approved by
the underwriting company unless otherwise specifically stated. A
physical and/or background inspection may be done to verify the
information provided. The quote(s) will be based up on the
underwriting information you supplied and the quote(s) is/are
subject to change upon inspection and review by the underwriting
company. The underwriting company reserves the right to determine
the final coverage, premium and acceptability If you have any
questions regarding the information collected, please contact the
agency. All quotes are provided by DEL AMO Insurance Services, Inc,.
DBA: InsComp Insurance Services and/or one of it's affiliated
agents, brokers, agencies, brokerages, and/or companies; Lic:
0B93601; . Commercial use by others
is prohibited by law. No portion of any news or information from
this website may be photocopied, faxed, mailed, distributed,
transmitted, published, broadcasted, duplicated, or re-distributed
in any manner for any purpose without prior written authorization of
its owner.
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