PLAN 8 – VSP
| 1 exam every 12 months | No copay in network $50.00 copay out of network |
| Frames every 24 months | $110.00 in network $80.00 Costco $70.00 out of network |
| Lenses every 12 months | No copay for standard single vision Progressive $80–$90 $50.00 out of network |
| Contacts every 24 months | $130.00 in lieu of glasses $105.00 out of network |
PLANS III (3), V (5) & VI (6):
| Maximum Vision Care Benefit per Fiscal year: | |
|---|---|
| Eye Refaction | $60.00 |
| Frames & Single Vision Lenses | $150.00 |
| Frames & Bi-Focal Lenses | $160.00 |
| Frames & Tri-Focal Lenses | $170.00 |
| Frames & Progressive Lenses | $170.00 |
| Lenticular Lenses (per pair) | $170.00 |
| Contact Lenses (in lieu of glasses) | $150.00 |
PLAN II (2):
| Maximum Vision Care Benefit per Fiscal year: | Plan II Co-Pays | |
|---|---|---|
| Eye Refraction | $50.00 | $10.00 |
| Frames & Single Vision Lenses | $90.00 | $60.00 |
| Frames & Bi-Focal Lenses | $100.00 | $60.00 |
| Frames & Tri-Focal Lenses | $110.00 | $60.00 |
| Frames & Progressive Lenses | $110.00 | $60.00 |
| Lenticular Lenses (per pair) | $110.00 | $60.00 |
| Contact Lenses (in lieu of glasses) | $90.00 | $60.00 |
Poly-Carb Lenses are ok. If packaged and under allowable amount, A/R Coating & Scratch Resistant Coating are ok.
ITEMS NOT COVERED:
BILLING ADDRESS:
IPM HEALTH & WELFARE TRUST OF CALIFORNIA
1168 E. LA CADENA DRIVE
RIVERSIDE, CA 92507
(951) 684-1791
HOURS: 8:00 AM TO 4:30 PM (M-F)
