Regence account, selecting “Find care,” and selecting “Vision.” See the Directory pages at the beginning of this booklet for links and contact information. Members under age 19 do not have out-of-network provider benefits. • VSP Choice network provider: When you choose to see a VSP Choice network provider for covered preventive vision care, you pay $0 of the allowed amount and the plan pays 100 percent of the allowed amount. Select a VSP Choice network provider who participates in the Premier Program to receive the best value for lenses and frames or contact lenses. VSP providers who participate in the Premier Program provide access to special offers and savings. • Out-of-network provider: For members age 19 or older, out-of-network providers will cost you more. See the table below for more information. Members under age 19 do not have out-of-network benefits. ALERT! This benefit covers only services that meet the requirements below. If you receive services during a comprehensive routine eye exam and your provider bills your visit as a medical treatment instead of as a routine service, the services are not covered as routine. Instead, when medically necessary, they may be covered under your medical benefits. See the “Vision care (diseases and disorders of the eye)” benefit for more information. Adults (age 19 or older) This section explains how the plan pays for covered services for members age 19 or older. The explanation includes information about maximum benefits, covered services, and payment. The below VSP coverage table applies to adults and dependents age 19 or older. Benefit Frequency Your cost with a VSP Choice Your cost with an out-of- network provider network provider Professional One per calendar You pay $0 of the allowed You pay 100% of billed comprehensive year. amount and the plan pays charges. routine eye 100% of the allowed amount. VSP will reimburse you up to exams $45 when you submit a claim for a covered exam. Frames One every two You pay $0 up to a $150 frame You pay 100% of billed calendar years. allowance; or charges. You pay $0 up to an $80 frame VSP will reimburse you up to allowance for Walmart®, $70 when you submit a claim for covered frames. Sam’s Club®, or Costco® providers. 80 2024 UMP Classic (PEBB) Certificate of Coverage