Benefit Frequency Your cost with a VSP Your cost with an out- Choice network provider of-network provider and the plan pays 100% of the allowed amount. Note: Walmart®, Sam’s Club ®, and Costco® providers are not VSP Choice network providers for children under age 19 for frames, lenses, and contact lenses. Call VSP Member Services at 1-844-299-3041 for out-of-network plan details or TTY 1-800-428-4833. 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. Vision hardware Lenses for glasses 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 once every calendar year for one set of covered glass or plastic lenses. Frames You pay $0 of the allowed amount and the plan pays 100 percent of the allowed amount for one covered frame every calendar year when you see a VSP Choice network provider. Contact lenses • You pay $0 of the allowed amount and the plan pays 100 percent of the allowed amount for elective contact lenses or necessary contact lenses in lieu of frames and lenses once every calendar year when you see a VSP Choice network provider. • You pay $0 and the plan pays 100 percent of the allowed amount for contact lens evaluation and fitting exam when you see a VSP Choice network provider. Low vision benefit ALERT! Out-of-network providers are not covered for any low vision services. 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 at no cost to you when the services are provided by a VSP Choice network provider. These services and equipment are subject to the limitations stated below. Contact your VSP Choice network provider for more information. 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 2024 UMP Classic (PEBB) Certificate of Coverage 85