Amounts shown below are your responsibility . Only In - Network benefits are shown Amounts shown below are your responsibility . Only In - Network benefits are shown Primary Vision Care Services (PVCS) Superior Vision Copays $0 Exam Non - Network: $40 Cost of Materials $10 Exam $25 Materials Routine Eye Exam No Limit on Frequency Once Per Calendar Year Lenses No Limit on Number of Pairs Non - Network: $60 Once Per Calendar Year Frames No Limit on Number of Frames You Pay Wholesale Cost Once Per Calendar Year $150 Allowance Contact Lens Fitting & Evaluation $50 Soft / $75 Gas Permeable / $150 Hybrid Copay Once Per Calendar Year $25 Copay Contacts No Limit on Number of Pairs You Pay Wholesale Cost Once Per Calendar Year $150 Allowance Unity Vision VSP Copays $15 Exam $15 Materials $10 Exam $25 Materials Non - Network: $45 Routine Eye Exam Once Per Calendar Year Once Per Calendar Year Lenses Once Per Calendar Year Once Per Calendar Year Frames $150 Allowance $170 Allowance Non - Network: $70 Contact Lens Fitting & Evaluation Applied to Contact Lens Allowance $60 Copay Contacts $150 Allowance in Lieu of Frames $120 Allowance in Lieu of Frames Vision