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