• 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: • 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. 82 2024 UMP Classic (PEBB) Certificate of Coverage