Elective Contact Lens
Necessary Contact Lens
Oversize Lens
Blended Bifocals
Progressive Multifocal
Polycarbonate
High Index
Photochromic
Polarized/Laminated
Ultra Violet Protection
Plano
Solid Tints and Dyes
Plastic Gradient Dye
Scratch Resistant Coating
Anti-Reflective Coating
Color Coating
Mirror and Ski Type Coating
Edge Treatments
Vision Therapy
Low Vision

N
R
Y
P
P
Y
Y
Y
N
P
N
Y
Y
Y
N
Y
N
Y
R
Y

Y

Yes, the item or benefit is provided under the patient's coverage

N

Not a benefit under the patient's plan If this item is provided, the patient benefit for lenses and frames will not be covered.

R

Requires prior authorization; the item or service must be medically necessary for the patient's visual welfare.

P

Patient pays additional costs and service fees according to VSP Patient Option List.