VOLUNTARY VISION: 

Standard Insurance Company

Balanced Care Vision

VSP Providers: 800-877-7195

http://www.Standard.com ("Find and Eye Doctor."  Then "VSP")

Group Number:   160-163441

IN-NETWORK BENEFITS:

EYE  EXAM:  $10 Copay every 12 months 

FRAMES:  Up to $130 reimbursement. Once every 12 months.

VSP provides a 20% discount for charges over the $130 allowance.

COSTCO allowances vary.

LENSES: $10 (Single, Bifocals, Trifocals, Lenticular). Every 12 months. 

Progressive Lens: Patient pays the difference between lined and progressive.        

Lens Options:

- Anti-reflective coating: $39 to $75

- Ultra Violet coating:  $14

- Scratch resistant coating: $15 to $29

- Standard Polycarbonate (child to age 18): No copay.  Adults $25.

- Photo-chromatic (glass and plastic): $27- $76

Conventional Elective Contacts (instead of glasses): $130 max reimbursement. The allowance can be applied to disposables, but the dollar amount must be used all at once. The provider will order either a three or six month supply.

​Contacts Fit and Follow-Up Exams: Patient cost up to $60.

Laser VisionCare: 

Average 15% discount (or 5% off promotional offer) for LASIK, Custom LASIK and PRK at participating V.S.P. Network and Affiliates providers.

The max out-of-pocket is $1,800 for LASIK and $2,300 for Custom LASIK using Wavefront technology.

The max out-of-pocket for PRK is $1,500.

In order to receive the benefit, a V.S.P. provider must coordinate the procedure.

__________________________________________________

Non-Network Benefits after deductible:

Exam Allowance: Up to $50 reimbursement

Frames allowances: Up to $70

Plastic lens max allowances: 

$50 Single Vision

$75 Lined Bifocals

$100 Lined Trifocals

$125 Lenticular

Contacts (Elective): Up to $105

Contacts (Medically necessary:  Up to $210

Frames: Up to $70

To submit out-of-network claims:

VSP (Vision Service Plan)

P.O. Box 997105

Lincoln, NE 68501-2622

This is a general overview. Carrier documents apply.