Employee Benefits Guide

Vision Insurance Plan ABC offers a vision insurance plan through Carrier Name. You have the freedom to choose any vision provider. However, you will maximize the plan benefits when you choose a Carrier Name network provider. If you choose an out-of-network provider, you may be responsible for paying in full at the time of service and submitting a claim to Carrier Name for reimbursement. Locate a Carrier network provider at www.website.com or call Member Services at 888-888-8888. The table below summarizes the key features of the vision plan. Please refer to the official plan documents for additional information on coverage and exclusions. If there are discrepancies between this chart and the Carrier Name plan document, the terms of the VSP plan document shall control. Choice Network Carrier Name Doctor Open Access (out of network) WellVision Eye Exam * $15 copay Reimbursed up to $45 Eyeglasses Single Vision Lenses Covered in full after $15 copay** Reimbursed up to $30 Eyeglasses Lined Biofocal Lenses Covered in full after $15 copay** Reimbursed up to $50 Eyeglasses Lined Trifocal Lenses Covered in full after $15 copay** Reimbursed up to $65 Eyeglasses Lenticular Lenses Covered in full after $15 copay** Reimbursed u to $100 Photochromics and Tints Covered in full No discounts Additional Lens Options 20% - 25% discount on non-covered lens options No discounts

Covered up to $180 after copay ($100 at Costco); $200 on featured frame brands. 20% off any amount over your frame allowance $160 allowance for elective and necessary contact lenses. 15% discount on contact lens exam. Contact lens exam copay not to exceed $60.

Frames

Reimbursed up to $70

Elective contact lenses are reimbursed up to $105. Necessary contact lenses are reimbursed up to $210.

Contact Lenses (in lieu of lenses and /or frames)

* Diabetic Eyecare Plus Program—$20 copay for follow-up exam relating to Type 1 and Type 2 diabetes. ** One materials copay per service year. Note: Exams and hardware are available only once in a 12-month period, starting with the first date of service/purchase.

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