ALERT! This benefit covers only services that meet the requirements below. If you receive services during a comprehensive routine eye exam and your provider bills your visit as a medical treatment instead of as a routine service, the services are not covered as routine. Instead, when medically necessary, they may be covered under your medical benefits. See the “Vision care (diseases and disorders of the eye)” benefit for more information. Adults (age 19 or older) This section explains how the plan pays for covered services for members age 19 or older. The explanation includes information about maximum benefits, covered services, and payment. The below VSP coverage table applies to adults and dependents age 19 or older. Benefit Frequency Your cost with a VSP Your cost with an out-of- Choice network provider network 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 amount. VSP will reimburse you up to exams $45 when you submit a claim for a covered exam. Frames One every two You pay $0 up to a $150 frame You pay 100% of billed calendar years. allowance; or charges. You pay $0 up to an $80 frame VSP will reimburse you up to allowance for Walmart®, $70 when you submit a claim for covered frames. Sam’s Club®, or Costco® providers. Lenses and One set every two You pay $0 for the following You pay 100% of billed enhancements calendar years. covered lenses and the plan charges. pays 100% of the allowed VSP will reimburse you up to amount: the following amounts when • Single vision lenses you submit a claim for • Lined bifocal lenses covered lenses: • Standard progressive lenses • $30 single vision lenses • Lined trifocal lenses • $50 lined bifocal lenses • Lenticular lenses • $50 standard progressive lenses Note: Lens enhancement is not • $65 lined trifocal lenses covered except for impact- • $100 lenticular lenses resistant coating for dependent children age 19 or older. 78 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage