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. When you see an out-of-network provider you pay 100 percent of the billed charges. VSP will reimburse you up to $45 when you submit a claim for covered services. When you receive services outside the country, you pay 100 percent of the billed charges. VSP will reimburse you up to $80 when you submit a claim for covered services. Vision hardware Lenses for glasses You pay $0 of the allowed amount and the plan pays 100 percent of the allowed amount once every two calendar years for one set of covered glass or plastic lenses: • Single vision lenses • Lined bifocal lenses • Lined trifocal lenses • Lenticular lenses • Standard progressive lenses • Lens enhancement covered for dependent children age 19 or older only: ▪ Impact-resistant coating When you see an out-of-network provider you pay 100 percent of the billed charges. When you submit a claim for covered lenses, VSP will reimburse you up to the following amounts: • $30 single vision lenses • $50 lined bifocal/standard progressive lenses • $65 lined trifocal lenses • $100 lenticular lenses When you receive services outside the country, you pay 100 percent of the billed charges. When you submit a claim for covered lenses, VSP will reimburse you up to the following amounts: • $70 single vision lenses • $80 lined bifocal/standard progressive lenses • $90 lined trifocal lenses • $125 lenticular lenses Frames The plan covers one frame every two calendar years: 80 2024 UMP Select (PEBB) Certificate of Coverage