BNY Mellon Benefits Guide
How the Plan Works
When you enroll in the plan, you have access to VSP's network of eye care doctors. Each time you need vision care, you decide whether to use an in-network provider or an out-of-network provider. You save money if you go through the VSP network for your services and supplies.
SERVICES
VSP NETWORK BENEFITS COVERAGE
FREQUENCY
Exam
Covered in full
One $10 copayment will be applied to the exam or eyewear purchased.
Every calendar year
Prescription Glasses Lenses
  • Single vision
  • Lined bifocal
  • Lined trifocal
Covered in full
Polycarbonate lenses for dependent children covered in full
Every calendar year
Frame
Covered up to $150 and 20% discount off any additional out-of-pocket expense
Every other calendar year
Contacts
Covered up to $130. This allowance applies to the cost of your contacts. The cost of the fitting and evaluation exam will be no more than $60. This exam is in addition to your vision exam to ensure proper fit of contacts.
Every calendar year (Contact lenses are in lieu of glasses. When you choose contacts, you will be eligible for frames two calendar years after the contacts were obtained.)
Laser Vision Correction
Average 15% off the regular price or 5% off the promotional price from contracted facilities
After surgery, use your frame allowance (if eligible) for sunglasses from any VSP doctor
Not applicable
SERVICES
NON-VSP NETWORK BENEFITS COVERAGE
FREQUENCY
Exam
Covered up to $50
One $10 copayment will be applied to the exam or eyewear purchased.
Every calendar year
Prescription Glasses Lenses:
  • Single vision
  • Lined bifocal
  • Lined trifocal
  • Lenticular
Single vision/covered up to $50
Lined bifocal/covered up to $75
Lined trifocal/covered up to $100
Lenticular lenses/covered up to $125
Every calendar year
Frame
Covered up to $70
Every other calendar year
Contacts
Elective contact lens covered up to $105
Medically necessary contact lens covered up to $210
This allowance applies to the cost of your lenses and the fitting and evaluation exam. This exam is in addition to your vision exam to ensure proper fit of contacts.
Every calendar year
(Contact lenses are in lieu of glasses. When you choose contacts you will be eligible for frames two calendar years after the contacts were obtained.)
Laser Vision Correction
None
Not applicable
EXTRA DISCOUNTS AND SAVINGS—WHEN VISITING A VSP NETWORK DOCTOR, YOU'LL RECEIVE
  • 30 percent off additional glasses and sunglasses, including lens options, from the same VSP doctor on the same day as your WellVision Exam. Or get 20 percent off from any VSP doctor within 12 months of your last WellVision Exam.
  • Average 35 to 40 percent savings on all non-covered lens options.
  • 15 percent discount off the cost of contact lens exam (fitting and evaluation).
Finding a Network Provider
To obtain a list of network providers in your area, or to request a claim form for out-of-network providers, call VSP at 1-800-877-7195 or go to www.vsp.com.
If you are reviewing provider information online, you may see a disclaimer stating that VSP cannot guarantee that the doctors on the list participate in your plan. Disregard this statement, as the BNY Mellon plan allows you to use the full network of VSP doctors.
In-Network Benefits
When you go to a network provider, you pay a $10 copayment. With in-network benefits, the plan covers the following:
  • one pair of eyeglass lenses, or contact lenses up to $130, each calendar year. Contact lenses can be delivered to your home. You pay the cost of any cosmetic features, such as bifocal lenses with no lines;
  • one pair of frames every two years, up to $150, with an additional 20 percent discount off any out-of-pocket expenses; and
  • laser vision correction (discounts only).
Out-of-Network Benefits
You may use providers who do not participate in the VSP network, but you will pay more. In addition, you must pay the provider in full out-of-pocket, then submit a claim to VSP. The plan will reimburse you a set dollar amount toward the cost of exams, lenses and frames.
Paying for Vision Services
The way you pay for vision services depends on the type of provider you use:
  • Network Provider – Contact your VSP provider to schedule an appointment. Let the provider know that you have VSP coverage, and ask the provider to obtain an authorization for you. At the time of your visit, pay the provider the required copayment and overages.
  • Out-of-Network Provider – Pay the provider directly, and submit a claim for reimbursement. Claim forms are available at www.vsp.com or by calling 1-800-877-7195. You must file claims within six months of the date services are received. You will need to provide the following information on your VSP claim form:
    • your provider's bill, including a detailed list of the services you received;
    • your VSP identification number;
    • your name, phone number and address;
    • the company name: BNY Mellon Corporation;
    • the patient's name, date of birth, phone number and address (if different from yours); and
    • the patient's relationship to you (for example, self, spouse, child).
The Vision Service Plan (VSP) includes coverage for exams, glasses or contact lenses, and discounts for laser surgery.