• $150 necessary contact lenses including any fitting/evaluation services Low vision benefit 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. These services and equipment are subject to the limitations stated below. Contact your VSP Choice network provider for more information. You pay 25 percent of the allowed amount for covered supplemental aids. The plan pays 75 percent of the allowed amount for medically necessary supplemental aids provided by VSP choice network providers and out-of-network providers. When you see an out-of-network provider for covered supplemental aids, you pay 100 percent of the billed charges. VSP will reimburse you up to 75 percent of the allowed amount when you submit a claim for covered aids. The maximum low vision benefit available is $1,000 (excluding your coinsurance) every two calendar years for supplemental examinations (testing) and supplemental aids combined when provided by VSP Choice network providers and out-of-network providers. There is a benefit maximum of two supplemental examinations (testing) and all supplemental aids combined. 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, you pay $0 and the plan pays 100 percent of the allowed amount. When you see an out-of-network provider you pay 100 percent of the billed charges. VSP will reimburse you up to $125 when you submit a claim for covered services. 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. Children (under age 19) ALERT! Out-of-network providers are not covered for any routine vision services. The below VSP coverage table applies to children under age 19. Benefit Frequency Your cost with a VSP Your cost with an out-of- Choice network network provider provider Professional One per calendar You pay $0 of the allowed You pay 100% of billed comprehensive year. amount and the plan pays charges. routine eye 100% of the allowed exams amount. 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage 81