• The VSP benefits do not cover investigational or experimental treatments or procedures (health interventions), services, supplies, and accommodations provided in connection with health interventions. ◦ Lens enhancements: The VSP benefits do not cover lens enhancements, including, but not limited to: • Anti-reflective coating; • Color coating; • Mirror coating; • Scratch-resistant coating;* • Blended lenses; • Cosmetic lenses; • Laminated lenses; • Oversize lenses; • Premium and custom progressive multifocal lenses; • Photochromic lenses; • Tinted lenses, except Pink #1 and Pink #2; • UV (ultraviolet) protected lenses;* and • Impact-resistant coating.* *These lens enhancements are covered for children under age 19. Impact-resistant coating is also covered for dependent children age 19 or older. ◦ Medical or surgical treatment of the eyes 129. Vision services and supplies: ◦ The plan does not cover services or supplies that are not medically necessary: • Plano lenses (less than a ± .50 diopter power). • Two pair of glasses instead of bifocals. • Services and/or materials not described as covered under this vision benefit. 130. Vitamin D screening and testing as part of routine screening 131. Weight control, weight loss, and obesity treatment: ◦ Non-surgical: Any program, drugs, services, or supplies for weight control, weight loss, or obesity treatment. Exercise or diet programs (formal or informal), exercise equipment, or travel expenses relating to non-surgical or surgical services are not covered. Such treatment is not covered even if prescribed by a provider, except as covered under "Bariatric surgery" (see page 44), “Diabetes Control Program” (see page 50), “Diabetes Prevention Program” (see page 51), “Nutrition counseling and therapy” (see page 64), or “Preventive care” (see page 66). ◦ Surgical: Any bariatric surgery procedure, any other surgery for obesity or morbid obesity, and any related medical services, drugs, or supplies, except when approved by preauthorization review. 132. Whole exome sequencing for: ◦ Uncomplicated autism spectrum disorder, developmental delay, mild to moderate global developmental delay. ◦ Other circumstances (e.g. environmental exposures, injury, infection) that reasonably explain the constellation of symptoms. ◦ Carrier testing for “at risk” relatives. ◦ Prenatal or pre-implantation testing. 116 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage