Vision hardware Lenses for glasses You pay $0 of the allowed amount and the plan pays 100 percent of the allowed amount when you see a VSP Choice network provider once every calendar year for one set of covered glass or plastic lenses. Frames You pay $0 of the allowed amount and the plan pays 100 percent of the allowed amount for one covered frame every calendar year when you see a VSP Choice network provider. Contact lenses • You pay $0 of the allowed amount and the plan pays 100 percent of the allowed amount for elective contact lenses or necessary contact lenses in lieu of frames and lenses once every calendar year when you see a VSP Choice network provider. • You pay $0 and the plan pays 100 percent of the allowed amount for contact lens evaluation and fitting exam when you see a VSP Choice network provider. Low vision benefit ALERT! Out-of-network providers are not covered for any low vision services. The plan covers low vision benefits when vision loss is sufficient enough to prevent reading and performing daily activities with standard corrective eyewear. If you fall within this category, you are entitled to professional services, as well as ophthalmic materials at no cost to you when the services are provided by a VSP Choice network provider. These services and equipment are subject to the limitations stated below. Contact your VSP Choice network provider for more information. Supplemental examinations (testing) You may receive up to two medically necessary supplemental tests (complete low vision analysis and diagnosis), including a comprehensive examination of visual functions, and the prescription of corrective eyewear or low vision aids when noted by the provider every two calendar years when you see a VSP Choice network provider. Supplemental aids The plan pays for covered supplemental aids every two calendar years, which may include: • Optical and non-optical aids; and • Training on how to use the aids. Vision claims administration This section explains how VSP administers claims. How to submit a vision claim for reimbursement When you visit a VSP Choice network provider, the doctor will submit the claim directly to VSP for payment. If you are a member and are age 19 or older and you see an out-of-network provider, you pay 100 percent of the billed charges. You can submit the claim online or by mail. See the Directory pages at the beginning of this booklet for links and contact information. 2024 UMP CDHP (PEBB) Certificate of Coverage 85