When you see a VSP Choice network provider: • The plan pays up to $150 for elective contacts. You pay a $30 copay when you receive contact lens evaluation and fitting exam at the time of service. You also pay any amount over $150. • The plan pays 100 percent of the allowed amount for necessary contact lenses. You pay a $30 copay when you receive contact lens evaluation and fitting exam at the time of service. When you see an out-of-network provider you pay 100 percent of the billed charges. When you submit a claim, VSP will reimburse you up to the following amounts: • $105 for elective contacts including any fitting/evaluation services • $210 for necessary contact lenses including any fitting/evaluation services When you receive services from outside the country you pay 100 percent of the billed charges. When you submit a claim, VSP will reimburse you up to the following amounts: • $150 elective contacts including any fitting/evaluation services • $150 necessary contact lenses including any fitting/evaluation services Low vision benefit The plan covers low vision benefits when vision loss is sufficient enough to prevent reading and performing daily activities with standard corrective eyewear. If you fall within this category, you are entitled to professional services, as well as ophthalmic materials. These services and equipment are subject to the limitations stated below. Contact your VSP Choice network provider for more information. You pay 25 percent of the allowed amount for covered supplemental aids. The plan pays 75 percent of the allowed amount for medically necessary supplemental aids provided by VSP choice network providers and out-of-network providers. When you see an out-of-network provider for covered supplemental aids, you pay 100 percent of the billed charges. VSP will reimburse you up to 75 percent of the allowed amount when you submit a claim for covered aids. The maximum low vision benefit available is $1,000 (excluding your coinsurance) every two calendar years for supplemental examinations (testing) and supplemental aids combined when provided by VSP Choice network providers and out-of-network providers. There is a benefit maximum of two supplemental examinations (testing) and all supplemental aids combined. Supplemental examinations (testing) You may receive up to two medically necessary supplemental tests (complete low vision analysis and diagnosis), including a comprehensive examination of visual functions, and the prescription of corrective eyewear or low vision aids when noted by the provider every two calendar years. When you see a VSP Choice network provider, you pay $0 and the plan pays 100 percent of the allowed amount. When you see an out-of-network provider you pay 100 percent of the billed charges. VSP will reimburse you up to $125 when you submit a claim for covered services. Supplemental aids The plan pays for covered supplemental aids every two calendar years, which may include: • Optical and non-optical aids; and • Training on how to use the aids. 2024 UMP Classic (PEBB) Certificate of Coverage 83