• When you see a VSP Choice network provider, the plan pays up to $150. You pay any amount over $150. • When you see an out-of-network provider you pay 100 percent of the billed charges. VSP will reimburse you up to $70 when you submit a claim. • When you see a VSP approved wholesale/retail vendor the plan pays up to the VSP approved wholesale/retail limit of $80. You pay any amount over $80. VSP approved wholesale/retail vendors include both community-based providers, as well as national retail chains. For a list of wholesale/retail vendors, contact VSP Member Services at 1-844-299-3041 or TTY 1-800-428-4833. • When you receive services outside the country, you pay 100 percent of the billed charges. When you submit a claim, VSP will reimburse you up to $150. Contact lenses The plan covers elective contact lenses or necessary contact lenses in lieu of frames and lenses once every two calendar years. • Elective contact lenses are contact lenses that are covered under the frame limit in lieu of coverage for eyeglasses. • Necessary contact lenses are contact lenses that are prescribed by your provider for other than elective or cosmetic purposes. Necessary contact lenses are used to treat specific conditions for which contact lenses provide better visual correction. When you see a VSP Choice network provider: • The plan pays up to $150 for elective contacts. You pay a $30 copay when you receive contact lens evaluation and fitting exam at the time of service. You also pay any amount over $150. • The plan pays 100 percent of the allowed amount for necessary contact lenses. You pay a $30 copay when you receive contact lens evaluation and fitting exam at the time of service. When you see an out-of-network provider you pay 100 percent of the billed charges. When you submit a claim, VSP will reimburse you up to the following amounts: • $105 for elective contacts including any fitting/evaluation services • $210 for necessary contact lenses including any fitting/evaluation services When you receive services from outside the country you pay 100 percent of the billed charges. When you submit a claim, VSP will reimburse you up to the following amounts: • $150 elective contacts including any fitting/evaluation services • $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. 2024 UMP Select (PEBB) Certificate of Coverage 81