Materials Coverage – VSP Advantage PlanSM
Coverage typically includes necessary prescription lenses and a frame up to a client-specified retail allowance, or an allowance toward contact lenses. Please review the patient’s coverage before providing materials.
Patients are also eligible for benefits on additional materials (see Value Added Benefits below).
Lenses
Spectacle lens coverage under the VSP Advantage Plan is designed to provide necessary lenses covered in full. Your base lens payment includes your reimbursement for the following:
- Single vision, bifocal, trifocal, or lenticular lenses in plastic or glass
- Eye size up to and including 60mm
- Polycarbonate lenses for dependent children, monocular patients, and handicapped patients
- Lined multifocal lenses in all segment widths, including occupational lenses. See the Dispensing & Lens Enhancements section of the VSP Manual for specific details on occupational lenses
- Prism and slab off
- Base curves (regardless of curve)
Note:
We only cover lenses that meet the minimum prescription criteria, unless your patient is eligible for plano lenses.
Here’s our minimum prescription criteria:
The combined power in any meridian is ±0.50 diopters or greater in at least one eye or one of the following exceptions occurs:
—Necessary prism of 0.50 diopters or greater in at least one eye.
—Anisometropia is 0.50 diopters or greater.
—Cylinder power is ±0.50 diopters or greater.
Other Lens Enhancements
If your patient selects a lens enhancement that is covered with copay, collect the lens enhancement copay directly from the patient. You’ll be charged back the VSP Advantage Plan charge-back fee for those lens enhancements.
Covered with Additional Copay
For lens enhancements that are covered with additional copay, charge the patient the patient copay listed in the VSP Advantage Network Lens Enhancements Chart or 80% of your U&C fees, whichever is lower.
Covered with Additional Copay, 80% U&C
For lens enhancements not listed on the VSP Advantage Network Lens Enhancements Chart, charge 80% of your U&C fees.
Patient Charges
The following examples illustrate how to calculate “add-on” fees based on your total prices for a specific lens enhancement:
| Your U&C fee for Mid-Index is: | $260 |
| Subtract your U&C fee for Mid-Index in plastic: | -$200 |
| Your U&C add-on fee is: | $60 |
| Deduct 20%: | -$12 |
| 80% of your U&C add-on fee: | $48 |
| Add the VSP Advantage Plan patient fee for Progressive F – Plastic (FA): | $105 |
| Patient pays: | $153 |
| Your U&C fee for near variable focus plastic is: | $180 |
| Subtract your U&C fee for bifocals (FT28): | -$130 |
| Your U&C add-on fee is: | $50 |
| Deduct 20%: | -$10 |
| Patient pays: | $40 |
Covered Lens Enhancements
If your patient chooses a covered lens enhancement, you’ll receive the VSP Advantage Plan covered service fee. We won’t apply a charge back.
Flexible Lens Enhancements
To offer more customized coverage to clients and members, we’ve developed several flexible lens enhancement programs that allow partial coverage for the most popular VSP lens enhancements, including anti-reflective (AR) coatings, photochromics, and progressives. Always refer to the Patient Record Report and Lens Enhancements Charges Report for complete information on lens enhancement coverage. The VSP Flexible Lens Enhancements Coverage Tip Sheet provides more information and helps you calculate patients' out-of-pocket expenses.
Frames
Note:
We’ll only cover frames when the lenses meet the minimum prescription criteria, unless your patient is eligible for plano lenses.
VSP Advantage Plan patients receive a client-defined retail frame allowance. We’ll pay you 55% of the retail price of the frame, up to 55% of the patient’s retail frame allowance. Charge 80% of U&C on the retail frame overage.
Effective January 1, 2014, most patients with a VSP Advantage Plan will have an extra $20 on top of their frame allowance when they select Marchon® or Altair® frames. Look for the retail allowances for Marchon/Altair and all other frames indicated on the Patient Record Report at authorization. You’ll be reimbursed up to 55% of the patient’s retail frame allowance for the frame brand dispensed.
Bill all frames as “doctor supplied” since we’re paying you directly. Your practice is responsible for paying the lab for any lab-supplied frames.
Contact Lenses
Many clients provide coverage for contact lenses in lieu of prescription glasses. To be eligible for contact lens coverage, a patient must usually first be eligible for eyeglasses. Check the Patient Record Report for the patient’s specific type of coverage and contact lens allowances. Refer to Contact Lens Benefits in the VSP Manual for more information.
Value Added Benefits
The benefits below are considered a private transaction between you and your patient. The patient is fully responsible for the payment of any additional items.
Glasses
Charge 80% of U&C for additional materials when complete pairs of prescription and non-prescription glasses, sunglasses, and blue light filtering glasses are dispensed within 12 months of the exam. The benefit:
- is based on your total U&C fee;
- is unlimited for 12 months on or following the date of the last covered eye exam;
- is available through any VSP doctor. Use professional judgment when evaluating prescriptions from another provider. You may request an additional exam at a 80% of U&C;
- applies to prescription and non-prescription lenses;
- doesn’t apply to cleaning products or repairs of prescription lenses or frames.
Note:
If a patient has coverage for lenses every 12 months and a frame every 24 months, charge 80% of U&C for the frame in the year when the patient is eligible for lenses but not for frame.
Contact Lenses
Charge 85% of U&C on contact lens exam services (fitting and evaluation). This benefit:
- is subtracted from your U&C fee for evaluation, fitting, and follow-up services for prescription contact lenses;
- is unlimited for 12 months on or following the date of the covered eye exam;
- is available through any VSP doctor. Use professional judgment when evaluating prescriptions from another provider. You may request an additional exam at 80% of U&C;
- doesn’t apply to lenses, solution, cleaning products, and service agreements.
Retinal Screening Value Added Feature
- Patients are eligible for routine retinal screening as a value added feature to complement their WellVision Exam® benefit.
- Please see the Retinal Screening section of the VSP Manual for more information.
VSP Laser VisionCareSM Program
Members receive a complimentary screening as well as preoperative and postoperative services through participating VSP doctors.
The program includes access to either Photorefractive Keratectomy (PRK) or Laser In-Situ Keratomileusis (LASIK) at a reduced cost, up to a maximum fee to the patient of $1,500 per eye for PRK, $1,800 per eye for LASIK, and $2,300 per eye for Custom LASIK with wavefront technology using the microkeratome only or Bladeless LASIK.
If the laser center is offering a temporary price reduction, VSP members will receive 5% off the advertised price if it is less than the usual discount price.
Please visit VSPOnline and reference the Laser VisionCare ProgramSM page under Plans & Coverages for information on how to participate and a list of participating facilities.
Supplemental Plans
The VSP Advantage Plan may also be sold with the following supplemental plans:
Advantage Computer VisionCareSM Plan
Note: If your patient chooses a covered lens enhancement, there’s no charge. If your patient selects any other lens enhancements charge the patient according to the VSP Advantage Plan Lens Enhancements Chart or your U&C fees, whichever is lower. You may charge 80% of your U&C fees for lens enhancements not listed on the VSP Advantage Plan Lens Enhancements Chart. You’ll be charged back the VSP Advantage Plan lab fee for those lens enhancements.
See the VSP Computer VisionCare Plan section of the VSP Manual for more information.
Advantage Additional Pair
Note: If your patient chooses a covered lens enhancement, there’s no charge. If your patient selects any other lens enhancements charge the patient according to the VSP Advantage Plan Lens Enhancements Chart or your U&C fees, whichever is lower. You may charge 80% of your U&C fees for lens enhancements not listed on the VSP Advantage Plan Lens Enhancements Chart. You’ll be charged back the VSP Advantage Plan lab fee for those lens enhancements.
Doctors are paid Advantage fees for the materials dispensing. See Lab instructions for materials dispensed under these supplemental plans.
Reminder: Obtain a separate authorization for these plans and follow the plan information provided on the authorization.
See Services Subject to Review/Audit for information regarding material record keeping requirements.