Children (under age 19) ALERT! Out-of-network providers are not covered for any routine vision services. The below VSP coverage table applies to children under age 19. Benefit Frequency Your cost with a VSP Your cost with an out- Choice network provider of-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. exams Frames One per calendar You pay $0 of the allowed You pay 100% of billed year. amount and the plan pays charges. 100% of the allowed amount. Lenses and One set per calendar You pay $0 for the following You pay 100% of billed enhancements year. covered lenses and the plan charges. pays 100% of the allowed amount: • Single vision lenses • Lined bifocal lenses • Standard progressive lenses • Lined trifocal lenses • Lenticular lenses You pay $0 for the following lens enhancements and the plan pays 100% of the allowed amount: • Scratch-resistant coating • Ultraviolet (UV) protected lenses • Impact-resistant coating Contacts One set of contact You pay $0 of the allowed You pay 100% of billed lenses or disposable amount for elective or charges. contact lenses up to necessary contact lenses and the maximum the plan pays 100% of the allowance instead of allowed amount. frames and lenses You pay $0 of the allowed every calendar year. amount for contact lens evaluation and fitting exam 84 2024 UMP Classic (PEBB) Certificate of Coverage