Vision Benefits Summary VSP Choice Plan 6

Vision Benefit Summary Dash Delivery Inc. Frequency Contacts (in lieu of glasses) 12 months Exams 12 months Frames 12 months Lenses 12 months Copayments 1 Contact lens fitting & evaluation Up to $60 copay Exams $10 Materials $25 In network allowances Covered Lens Enhancements Polycarbonate for children Elective Contact Lenses $130 $130 / 20% savings on amount over 2,3,4 Retail Frame Value allowance 1 Patient will pay 85% of doctor's U&C fees or $60, whichever is less. 2 Extra $20 allowance on featured brands. Featured frame brands and promotion subject to change. 3 Frame allowance backed by a wholesale guarantee, meaning VSP fully covers more frames than retail allowance plans. 4 Allowance may differ at Walmart, Sam's Club and Costco, however it is of equivalent value. VSP QUESTIONS? VSP OUT-OF-NETWORK REIMBURSEMENT CLAIMS (800) 877 7195 PO Box 495918, Cincinnati, OH 45249-5918 BM-SOB-0036-202306

Value added programs SM Diabetic Eyecare Plus Program Included Diabetic exam reminder letters Included Health-focused care Included Hearing aid discounts Included Low vision Included Out-of-network allowances Bifocal lenses, up to $50 Elective contact lens materials and fitting/evaluation, up to $105 Examination, up to $45 Frame, up to $70 Lenticular lenses, up to $100 Single vision lenses, up to $30 Trifocal lenses, up to $65 Extra discounts & savings 5 Additional pairs of glasses 20% savings Laser vision correction (LVC) Average 15% Discount Average savings of 30% on other lens Lens enhancements enhancements 5 20% savings on unlimited additional pairs of prescription or non-prescription glasses/sunglasses, including lens enhancements, from a VSP provider within 12 months of your last WellVision Exam®. VSP QUESTIONS? VSP OUT-OF-NETWORK REIMBURSEMENT CLAIMS (800) 877 7195 PO Box 495918, Cincinnati, OH 45249-5918 BM-SOB-0036-202306

This benefit summary is not a complete description of the insurance coverage. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater details. Should there be a difference between this summary and the contract, the contract will govern. Vision insurance product underwritten by National Guardian Life Insurance Company (NGL), Madison, WI, marketed by Beam Insurance Services LLC (Beam Benefits Insurance Services LLC, in CA). Policy form number NVIGRP 2020. Vision product underwritten by Nationwide Life Insurance Company, Columbus, OH in DE, ID, NY, LA, UT, OH, TX and NM. Vision coverage applicable to policy form GVIS AO L20, or state equivalent. Vision insurance products underwritten by Vision Service Plan (VSP) in WA. Not all products available in all states. Vision product administered by Vision Service Plan Insurance Company. VSP is a registered trademark of Vision Service Plan. VSP, VSP Choice Plan, and WellVision Exam are registered trademarks and Diabetic Eyecare Plus Program is a service mark of Vision Service Plan. All other brands or marks are the property of their respective owners. ©2024 Vision Service Plan. All rights reserved. Two life groups made up of only a husband-wife, domestic partners or same-sex couple are not eligible for coverage. National Guardian Life Insurance Company, Madison, WI, is not affiliated with The Guardian Life Insurance Company of America, a.k.a. The Guardian, or Guardian Life. VSP is a registered trademark of Vision Service Plan. Nationwide and Beam Insurance Services LLC are separate and non-affiliated companies. National Guardian Life Insurance Company, Two East Gilman, Madison, Wisconsin 53703 Nationwide Life Insurance Company, One Nationwide Plaza, Columbus, OH 43215 Vision Service Plan Insurance Company, 3333 Quality Drive Rancho Cordova, CA 95670 VSP QUESTIONS? VSP OUT-OF-NETWORK REIMBURSEMENT CLAIMS (800) 877 7195 PO Box 495918, Cincinnati, OH 45249-5918 BM-SOB-0036-202306