Vision - Community Health Plan of Washington - Medicare Advantage

Vision Coverage Is Offered on All Plans

Vision Providers

We work with Vision Services Plan, or VSP, to provide you with a supplemental vision benefit. The VSP Choice Network provides you with a list of contracted providers. You may go to any of our network providers listed in the VSP Choice Network Directory below for $0 copay eye exams. While you are a member of our plan, you must use network providers to get your covered services except in limited cases such as emergencies or urgently needed out-of-area care. With the exception of emergencies or urgent care, it may cost more to get care from out-of-network providers.

➔ 2019 Vision Network Directory (English and Spanish)
➔ 2020 Vision Network Directory (English and Spanish)

Coverage includes:

  • One yearly eye exam (including glaucoma screening) to diagnose and treat conditions of the eye.
  • Prescription eyeglass frames, lenses, and contacts: up to $150 benefit limit every two years
  • Plan 014 members: prescription eyeglass frames, lenses, and contacts: up to $400 benefit limit every two years
  • Following cataract surgery, there is a supplement for one pair eyeglasses or one set of contact lenses included, however, you must pay 20% of the market cost.

Certain eye and vision services are not covered:

  • Radial keratotomy
  • LASIK surgery
  • Vision therapy
  • Low Vision Aid

Out of Network Vision Care

If you choose to receive vision care or obtain hardware (eyeglass lenses or frames) outside of the VSP Choice Network, VSP will reimburse you for up to $47 toward one out-of-network routine eye exam every year. Vision hardware will be reimbursed at a reduced rate. Contact Customer Service for more information

2020 Vision Benefits by Plan

MA Plan 006

Routine Eye exam with a VSP provider: $0 copay, limit one exam per year. If an out-of-network provider is used, a supplement of $47 can be applied toward total cost.

Specialty eye exam to diagnose conditions and diseases of the eye: $40 copay. If provider is in-network, then physician referral is required. If provider is out-of-network, then prior authorization is required.

Eye wear including lenses for eyeglasses, frames, and contact lenses with a $0 copay for one pair of glasses and total benefit of $150 every two years.

The remaining cost you pay out-of-pocket. Members must use a VSP network provider.

Out-of-Network Lenses – amount allowed toward cost:

  • Single Vision: $30
  • Lined bifocal or Progressive: $50
  • Lined trifocal: $75
  • Lenticular: $75

Out-of-Network Frames or Contact Lenses – amount allowed toward cost:

  • Frame: $45
  • Contact lenses: $85
MA Pharmacy Plan 008

Routine Eye exam with a VSP provider: $0 copay, limit one exam per year. If an out-of-network provider is used, a supplement of $47 can be applied toward total cost.

Specialty eye exam to diagnose conditions and diseases of the eye: $40 copay. If provider is in-network, then physician referral is required. If provider is out-of-network, then prior authorization is required.

Eye wear including lenses for eyeglasses, frames, and contact lenses with a $0 copay for one pair of glasses and total benefit of $150 every two years.

The remaining cost you pay out-of-pocket. Members must use a VSP network provider.

Out-of-Network Lenses – amount allowed toward cost:

  • Single Vision: $30
  • Lined bifocal or Progressive: $50
  • Lined trifocal: $75
  • Lenticular: $75

Out-of-Network Frames or Contact Lenses – amount allowed toward cost:

  • Frame: $45
  • Contact lenses: $85
MA Pharmacy Plan 009

Routine Eye exam with a VSP provider: $0 copay, limit one exam per year. If an out-of-network provider is used, a supplement of $47 can be applied toward total cost.

Specialty eye exam to diagnose conditions and diseases of the eye: $40 copay. If provider is in-network, then physician referral is required. If provider is out-of-network, then prior authorization is required.

Eye wear including lenses for eyeglasses, frames, and contact lenses with a $0 copay for one pair of glasses and total benefit of $150 every two years.

The remaining cost you pay out-of-pocket. Members must use a VSP network provider.

Out-of-Network Lenses – amount allowed toward cost:

  • Single Vision: $30
  • Lined bifocal or Progressive: $50
  • Lined trifocal: $75
  • Lenticular: $75

Out-of-Network Frames or Contact Lenses – amount allowed toward cost:

  • Frame: $45
  • Contact lenses: $85
MA Extra Plan 010

Routine Eye exam with a VSP provider: $0 copay, limit one exam per year. If an out-of-network provider is used, a supplement of $47 can be applied toward total cost.

Specialty eye exam to diagnose conditions and diseases of the eye: $40 copay. If provider is in-network, then physician referral is required. If provider is out-of-network, then prior authorization is required.

Eye wear including lenses for eyeglasses, frames, and contact lenses with a $0 copay for one pair of glasses and total benefit of $150 every two years.

The remaining cost you pay out-of-pocket. Members must use a VSP network provider.

Out-of-Network Lenses – amount allowed toward cost:

  • Single Vision: $30
  • Lined bifocal or Progressive: $50
  • Lined trifocal: $75
  • Lenticular: $75

Out-of-Network Frames or Contact Lenses – amount allowed toward cost:

  • Frame: $45
  • Contact lenses: $85
MA Special Needs Plan 014

Routine eye exam with a VSP provider: 0% of the cost, limit one exam per year. If an out-of-network provider is used, a supplement of $47 can be applied toward total cost.

Specialty eye exam to diagnose conditions and diseases of the eye: 0% of the cost. If provider is in-network, then physician order is required. If provider is out-of-network, then plan approved referral is required.

Eye wear including lenses for eyeglasses, frames, and contact lenses with a $0 copay for one pair of glasses and total benefit of $400 every two years.

The remaining cost you pay out-of-pocket. Members must use a VSP network provider.

Out-of-Network Lenses – amount allowed toward cost:

  • Single Vision: $30
  • Lined bifocal or Progressive: $50
  • Lined trifocal: $60
  • Lenticular: $75

Out-of-Network Frames or Contact Lenses – amount allowed toward cost:

  • Frame: $45
  • Contact lenses: $85
MA Value Plan 016

Routine Eye exam with a VSP provider: $0 copay, limit one exam per year. If an out-of-network provider is used, a supplement of $47 can be applied toward total cost.

Specialty eye exam to diagnose conditions and diseases of the eye: $40 copay. If provider is in-network, then physician referral is required. If provider is out-of-network, then prior authorization is required.

Eye wear: Lenses for eyeglasses have a $0 copay for one pair of glasses every 2 years.

Frames or contact lenses have a $150 benefits toward total cost, every two year. The remaining cost you pay out-of-pocket.

Members must use VSP network.

Out-of-Network Lenses – amount allowed toward cost:

  • Single Vision: $30
  • Lined bifocal or Progressive: $50
  • Lined trifocal: $75
  • Lenticular: $75

Out-of-Network Frames or Contact Lenses – amount allowed toward cost:

  • Frame: $45
  • Contact lenses: $85

2019 Vision Benefits by Plan

MA Plan 006
Specialty eye exam to diagnose conditions and diseases of the eye: $40 copay. If the provider is in-network, then the physician order is required. If the provider is out-of-network, then plan approved referral is required.

Routine Eye exam with a VSP provider: $0 copay, limit one exam per year. If an out-of-network provider is used, a supplement of $47 can be applied toward the total cost.

Eyewear: Lenses for eyeglasses have a $0 copay for one pair of glasses every 2 years. Members must use VSP network. Frames or contact lenses have a $100 benefits toward the total cost. The remaining cost you pay out-of-pocket.

Out-of-Network Lenses – amount allowed toward cost:

  • Single Vision: $30
  • Lined bifocal or Progressive: $50
  • Lined trifocal: $75
  • Lenticular: $75

Out-of-Network Frames or Contact Lenses – amount allowed toward cost:

  • Frame: $45
  • Contact lenses: $85
MA Pharmacy Plan 008
Specialty eye exam to diagnose conditions and diseases of the eye: $40 copay. If provider is in-network, then physician order is required. If provider is out-of-network, then plan approved referral is required.

Routine Eye exam with a VSP provider: $0 copay, limit one exam per year. If an out-of-network provider is used, a supplement of $47 can be applied toward total cost.

Eye wear: Lenses for eyeglasses have a $0 copay for one pair of glasses every 2 years. Members must use VSP network. Frames or contact lenses have a $100 benefit toward total cost. The remaining cost you pay out-of-pocket.

Out-of-Network Lenses – amount allowed toward cost:

  • Single Vision: $30
  • Lined bifocal or Progressive: $50
  • Lined trifocal: $60
  • Lenticular: $75

Out-of-Network Frames or Contact Lenses – amount allowed toward cost:

  • Frame: $45
  • Contact lenses: $85
MA Pharmacy Plan 009
Specialty eye exam to diagnose conditions and diseases of the eye: $40 copay. If provider is in-network, then physician order is required. If provider is out-of-network, then plan approved referral is required.

Routine Eye exam with a VSP provider: $0 copay, limit one exam per year. If an out-of-network provider is used, a supplement of $47 can be applied toward total cost.

Eye wear: Lenses for eyeglasses have a $0 copay for one pair of glasses every 2 years. Members must use VSP network. Frames or contact lenses have a $100 benefit toward total cost. The remaining cost you pay out-of-pocket.

Out-of-Network Lenses – amount allowed toward cost:

  • Single Vision: $30
  • Lined bifocal or Progressive: $50
  • Lined trifocal: $60
  • Lenticular: $75

Out-of-Network Frames or Contact Lenses – amount allowed toward cost:

  • Frame: $45
  • Contact lenses: $85
MA Extra Plan 010
Specialty eye exam to diagnose conditions and diseases of the eye: 20% coinsurance. If provider is in-network, then physician order is required. If provider is out-of-network, then plan approved referral is required.

Routine Eye exam with a VSP provider: $0 copay, limit one exam per year. If an out-of-network provider is used, a supplement of $47 can be applied toward total cost.

Eye wear: Lenses for eyeglasses have a $0 copay for one pair of glasses every 2 years. Members must use VSP network. Frames or contact lenses have a $100 benefit toward total cost. The remaining cost you pay out-of-pocket.

Out-of-Network Lenses – amount allowed toward cost:

  • Single Vision: $30
  • Lined bifocal or Progressive: $50
  • Lined trifocal: $60
  • Lenticular: $75

Out-of-Network Frames or Contact Lenses – amount allowed toward cost:

  • Frame: $45
  • Contact lenses: $85
MA Special Needs Plan 014
Specialty eye exam to diagnose conditions and diseases of the eye: 0% of the cost. If provider is in-network, then physician order is required. If provider is out-of-network, then plan approved referral is required.

Routine Eye exam with a VSP provider: 0% of the cost, limit one exam per year. If an out-of-network provider is used, a supplement of $47 can be applied toward total cost.

Eye wear: Lenses for eyeglasses have a $0 copay for one pair of glasses every 2 years. Members must use VSP network. Frames or contact lenses have a $130 benefit toward total cost. The remaining cost you pay out-of-pocket.

Out-of-Network Lenses – amount allowed toward cost:

  • Single Vision: $30
  • Lined bifocal or Progressive: $50
  • Lined trifocal: $60
  • Lenticular: $75

Out-of-Network Frames or Contact Lenses – amount allowed toward cost:

  • Frame: $45
  • Contact lenses: $85
MA Value Plan 016
Specialty eye exam to diagnose conditions and diseases of the eye: 20% coinsurance. If provider is in-network, then physician order is required. If provider is out-of-network, then plan approved referral is required.

Routine Eye exam with a VSP provider: $0 copay, limit one exam per year. If an out-of-network provider is used, a supplement of $47 can be applied toward total cost.

Eye wear: Lenses for eyeglasses have a $0 copay for one pair of glasses every 2 years. Members must use VSP network. Frames or contact lenses have a $100 benefit toward total cost. The remaining cost you pay out-of-pocket.

Out-of-Network Lenses – amount allowed toward cost:

  • Single Vision: $30
  • Lined bifocal or Progressive: $50
  • Lined trifocal: $60
  • Lenticular: $75

Out-of-Network Frames or Contact Lenses – amount allowed toward cost:

  • Frame: $45
  • Contact lenses: $85

 

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