• Telemedicine or store and forward services for services that are not recognized as essential health benefits under section 1302(b) of the PPACA in effect on January 1, 2015 • Telemedicine or store and forward services that cannot be safely and effectively provided through telemedicine or store and forward technology • Telemedicine or store and forward services that use technology that does not meet state and federal requirements for privacy and security of protected health information • Telemedicine visits originating from a location other than the specified originating sites Vision care (diseases and disorders of the eye) You pay the standard rate under the medical benefit for treatment of diseases and disorders of the eye that are not part of a routine vision exam. Orthoptic therapy is not covered except for the diagnosis of strabismus, a muscle disorder of the eye. LASIK surgery is not covered. Following cataract surgery, vision hardware (contact lenses or eyeglasses, including frames and prescription lenses) is covered as DME (see page 52). These services are paid at the standard rate. Your routine vision benefits Vision coverage is provided by UMP, in collaboration with Regence Choice Vision Plan administered by Vision Service Plan (VSP). Regence BlueShield administers benefits for the treatment of diseases and disorders of the eyes. VSP administers benefits for routine eye exams and hardware (prescription lenses, frames or prescription contact lenses) and provides claims administration for this plan. When you have questions about treatment of diseases and disorders of the eyes contact UMP Customer Service. When you have questions about routine eye exams and hardware, call VSP Member Services at 1-844-299-3041 or TTY 1-800-428-4833. See the Directory at the beginning of the COC for vision services contact information. Finding a routine vision provider Get the most out of your UMP vision benefits and save money with a VSP Choice network provider. As a UMP member, you may search for a VSP Choice network provider for preventive (routine) vision services through the VSP website by logging in to your VSP account or by selecting “Find a doctor,“ and using the advanced search option to select “Choice” for “Doctor network.“ You can also search by signing in to your Regence account, selecting “Find care,” and selecting “Vision.” See the Directory pages at the beginning of this booklet for links and contact information. Members under age 19 do not have out-of-network provider benefits. • VSP Choice network provider: When you choose to see a VSP Choice network provider for covered preventive vision care, you pay $0 of the allowed amount and the plan pays 100 percent of the allowed amount. Select a VSP Choice network provider who participates in the Premier Program to receive the best value for lenses and frames or contact lenses. VSP providers who participate in the Premier Program provide access to special offers and savings. • Out-of-network provider: For members age 19 or older, out-of-network providers will cost you more. See the table below for more information. Members under age 19 do not have out-of-network benefits. 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage 77