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. When you submit a claim, attach an itemized receipt that includes the following information: • Doctor’s name or office name; • Name of patient; • Date of service; and • Each service received and the amount paid. Timely submitting of claims You have 12 months from the date of service to submit your claim. If you do not submit your claim within 12 months of the date of service, it will be denied. If you disagree with how your claim was processed, you may file a complaint or an appeal. 84 2024 UMP Select (PEBB) Certificate of Coverage