Benefit Frequency Your cost with a VSP Your cost with an out- Choice network provider of-network provider plan pays 100% of the allowed amount: • Scratch-resistant coating • Ultraviolet (UV) protected lenses • Impact-resistant coating Contacts One set of contact You pay $0 of the allowed You pay 100% of billed lenses or disposable amount for elective or charges. contact lenses up to necessary contact lenses and the maximum the plan pays 100% of the allowance instead of allowed amount. frames and lenses You pay $0 of the allowed every calendar year. amount for contact lens evaluation and fitting exam and the plan pays 100% of the allowed amount. Note: Walmart®, Sam’s Club ®, and Costco® providers are not VSP Choice network providers for children under age 19 for frames, lenses, and contact lenses. Call VSP Member Services at 1-844-299-3041 for out-of-network plan details or TTY 1-800-428-4833. Vision exam You pay $0 of the allowed amount and the plan pays 100 percent of the allowed amount when you see a VSP Choice network provider for one professional comprehensive routine eye examination with refraction or visual analysis per calendar year, including: • Prescribing and ordering proper lenses; • Verifying the accuracy of the finished lenses; and • Progress or follow-up work as necessary. Vision hardware Lenses for glasses You pay $0 of the allowed amount and the plan pays 100 percent of the allowed amount when you see a VSP Choice network provider once every calendar year for one set of covered glass or plastic lenses. Frames You pay $0 of the allowed amount and the plan pays 100 percent of the allowed amount for one covered frame every calendar year when you see a VSP Choice network provider. Contact lenses • You pay $0 of the allowed amount and the plan pays 100 percent of the allowed amount for elective contact lenses or necessary contact lenses in lieu of frames and lenses once every calendar year when you see a VSP Choice network provider. • You pay $0 and the plan pays 100 percent of the allowed amount for contact lens evaluation and fitting exam when you see a VSP Choice network provider. 2024 UMP Select (PEBB) Certificate of Coverage 83