◦ Tinnitus-masking counseling 120. Transcutaneous vagal nerve stimulation (does not include or apply to support of previous implanted VNS) 121. Transcutaneous vagal nerve stimulation for epilepsy or depression 122. Travel, transportation, and lodging expenses, except as specified for ambulance services covered by the plan (see page 37), or approved travel and lodging costs related to the COE Program for single knee and single hip replacement (see page 58) and for spine care (see page 71) 123. Treatment of varicose veins with Endovenous Laser Ablation (EVLA), Radiofrequency Ablation (RFA), Sclerotherapy, and Phlebectomy in patients with pregnancy, active infection, peripheral arterial disease, or deep vein thrombosis (DVT) 124. Upright magnetic resonance imaging (uMRI), also known as “positional,” “weight-bearing” (partial or full), or “axial loading” 125. Vagal nerve stimulation (VNS) for treatment-resistant depression 126. Vagal nerve stimulation (VNS) for the treatment of depression (does not include or apply to support of previously implanted VNS) 127. Vision hardware replacements: ◦ The plan does not cover the replacement of any lost, stolen or broken lenses and/or frames. 128. Vision, routine: ◦ Certain contact lens expenses: • Artistically-painted or non-prescription contact lenses; • Contact lens modification, polishing or cleaning; • Refitting of contact lenses after the initial (90-day) fitting period; • Additional office visits associated with contact lens pathology; and • Contact lens insurance policies or service agreements. ◦ Corrective vision treatment of an experimental or investigational nature • The VSP benefits do not cover investigational or experimental treatments or procedures (health interventions), services, supplies, and accommodations provided in connection with health interventions. ◦ Lens enhancements: The VSP benefits do not cover lens enhancements, including, but not limited to: • Anti-reflective coating; • Color coating; • Mirror coating; • Scratch-resistant coating;* • Blended lenses; • Cosmetic lenses; • Laminated lenses; • Oversize lenses; • Premium and custom progressive multifocal lenses; • Photochromic lenses; • Tinted lenses, except Pink #1 and Pink #2; • UV (ultraviolet) protected lenses;* and • Impact-resistant coating.* *These lens enhancements are covered for children under age 19. Impact-resistant coating is also covered for dependent children age 19 or older. 120 2024 UMP Classic (PEBB) Certificate of Coverage