Vision Plan

These vision benefits are administered by DeltaVision, in partnership with VSP. For additional information or to search for providers online, please visit the VSP website at www.vsp.com.

Delta VSP Vision Plan Policy #23526 Phone #: 800-877-7195
Benefit	Coverage with a VSP provider	Frequency
WellVision Exam	$10 copay	12 months
Glasses	$25 copay	24 months
Frame	$130 frame allowance $130 Walmart/Sam’s Club frame allowance $70 Costco® frame allowance 20% savings on any amount over your allowance	24 months
Lenses	Covered in full: Single vision lenses Lined bifocal lenses Lined trifocal lenses Lenticular lenses	12 months
Lense Enhancements	Member cost: Standard progressive lenses: $0 Impact-resistant lenses for dependent children: $0 Premium progressive: $95 - $105 Custom progressive: $150 - $175 Anti-reflective coating: $41 - $85 Light-reactive: $75 Tints: $15 - $17 (plastic only) Scratch resistant coating: $17 Average savings of 30% on other enhancements	12 months
Contact lenses (instead of glasses)		12 months
Elective contact lens exam (fitting and evaluation)	Up to $60 copay
Elective contact lenses	$130 allowance
Visually necessary contact lenses	Covered in full after $25 copay
Essential Medical Eye Care	Retinal imaging for members with diabetes covered-in-full. Additional exams and services beyond routine care to treat immediate issues from pink eye to sudden changes in vision or to monitor ongoing conditions such as dry eye, diabetic eye disease, glaucoma, and more. Copay $20; Coordination with your medical coverage may apply. Ask your VSP network doctor for details.	As needed
Extra discounts and savings
Glasses and sunglasses	20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12 months of your last WellVision Exam. Discover all current eyewear offers, contact lens rebates, lens satisfaction guarantees and more savings at vsp.com/offers.
Retinal screening	Max $39 copay on routine retinal screening as an enhancement to a WellVision Exam.
Laser vision correction	Average 15% off the regular price or 5% off the promotional price; discounts only available from VSP contracted facilities.
Coverage with out-of-network providers (OON allowance) Frame benefit is once per 24 months. All other benefits are once per 12 months.
Exam	up to $45
Frame	up to $70
Lenses	Single vision lenses: up to $30 Lined bifocal lenses: up to $50 Lined trifocal lenses: up to $65 Lenticular lenses: up to $100 Progressive lenses: up to $50
Contact lenses (instead of glasses)	Elective contact lenses: up $105 Necessary contact lenses: up to $210

For eligibility details, refer to the plan's Evidence/Certificate of Coverage (on file with your benefits administrator, plan sponsor or employer).

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