VSP’s Low Vision plan offers members low vision exams and low vision aids, up to a specified maximum, every two service years. Pre-service verification is required. Submit a Low Vision Verification Form.

A low vision evaluation is covered for members who present with moderate, severe, or profound visual impairment. A low vision evaluation includes, but is not limited to, a detailed case history, effectiveness of any low vision aids in use, visual acuity in each eye with best spectacle correction, steadiness of fixation, assessment of aids required for distance vision and near vision, evaluation of any supplemental aids, evaluation of therapeutic filters, development of treatment, counseling of patient, and advice to patient’s family (if appropriate).

We’ll cover Low Vision Evaluation and Aids if your patient’s best corrected visual acuity is 20/70 or worse in at least one eye, or if there is a visual field of 20 degrees or less, or a hemianopsia. The request and claim should contain the correct low vision diagnosis code(s).

Don’t use the Low Vision benefit to provide conventional glasses or additional contact lenses. Lenses covered under the Low Vision plan must be either specialty low vision lenses, or glasses specifically designed for use in conjunction with low vision aids. VSP’s minimum prescription requirements apply. Please include a manufacturer’s invoice when submitting a Low Vision Verification Form.

If your patient meets the benefit criteria above and is eligible for low vision benefits, obtain a case number. To get one, complete aLow Vision Verification Form. A copy of the invoice or catalog page is needed for each low vision aid requested. Fax the form to 916.851.4733. Or mail this form to: VSP, PO Box 997100, Sacramento, CA 95899. You can find this form under the Forms section of the Administration menu on VSPOnline on eyefinity.com, or in the Tools and Forms section of this manual.

Signature Plan and VSP Choice Service Allowance: $1,000 maximum benefit every two service years.

The maximum benefit includes coverage for two supplemental exams*. The remaining allowance is for materials.

*VSP covers additional exams if benefit dollars are available.

Coverage includes two low vision supplemental exams every two service years. We’ll pay up to $125 for each exam. Don’t balance bill for this service. There’s no copay.

Coverage includes an allowance for low vision aids every two years, including prescription services and optical aids. Your patient must pay any overages.

Non-covered low vision aids include, but are not limited to, the following items:

• Plano lenses (excepting lenses for patients with photophobia, as noted above)
• Fitovers/cocoons/clip-ons
• Electronic books
• Computers with voice-enhanced software
• Watches with large dials
• Lamps

Signature Plan and VSP Choice Plan: We’ll pay 75% of the covered amount up to $1,000 (minus any amount paid for supplemental exams) for each person every two service years. Bill your patient for the remaining 25% of the covered amount, plus any amount over the maximum benefit.

Patients with Sight for Students Gift Certificates: We'll pay 100% of the allowed amount up to $1,000 for each person every two service years.

Elements: VSP pays 100% of the billed amount. No maximum. No copay.

Medicaid: VSP pays 100% of the billed amount up to fee schedule. No copay or charge to the member for covered services. Based on state guidelines, refer to Medicaid Fee Schedule.

Submit Low Vision claims using our electronic claims submission system. You’ll need an authorization number, which can be found on the Benefit Authorization notice. Indicate the case number in Box 23 located on the Diagnosis and Services screen.

For proper payment, bill all covered services with the appropriate CPT or HCPCS codes from this list.

See Services Subject to Review/Audit for information regarding material record keeping requirements.