Vision Plan Summary

200 Park Ave., New York, NY 10166 L0423030985[exp0426][All States] © 2024 MetLife Services and Solutions, LLC Goshen Community Schools – VSP Choice Network Plan Summary Metropolitan Life Insurance Company In-network benefits There are no claims for you to file when you go to a participating vision provider. Simply pay your copay and, if applicable, any amount over your allowance at the time of service. With your Vision Preferred Provider Organization Plan, you can: • Go to any licensed vision provider and receive coverage. Just remember your benefit dollars go further when you stay in network. • Choose from a large network of ophthalmologists, optometrists, and opticians, from private practices to retailers like Costco® Optical, Walmart, Sam’s Club and Visionworks. In-network value added features: Additional lens enhancements: In addition to standard lens enhancements, enjoy an average 20-25% savings on all other lens enhancements.1 Savings on glasses and sunglasses: Get up to 20% savings on additional pairs of prescription glasses and non-prescription sunglasses, including lens enhancements. At times, other promotional offers may also be available.1 Laser vision correction: 2 Potential savings averaging 15% off the regular price or 5% off a promotional offer for laser surgery including PRK, LASIK and Custom LASIK. This offer is only available at MetLife participating locations. Frequency Eye exam Once every 12 months • Eye health exam, dilation, prescription and refraction for glasses: Covered in Full after a $10 copay. • Retinal imaging: Up to a $39 copay on routine retinal screening when performed by a private practice. Frame Once every 24 months • Allowance: $130. $150 on featured frames • Costco®, Walmart® and Sam’s Club®: $70 allowance. You will receive an additional 20% savings on the amount that you pay over your allowance. This offer is available from all participating locations except Costco®, Walmart® and Sam’s Club®. Standard corrective lenses Once every 12 months • Single vision, lined bifocal, lined trifocal, lenticular: Covered in Full after $25 eyewear copay. Standard lens enhancements1 Once every 12 months • Standard Polycarbonate (child up to age 18) and Ultraviolet (UV) coating : Covered in Full. • Progressive Premium/Custom, Standard Polycarbonate (adult), Scratch-resistant coatings, Solid or Gradient Tints, Anti-reflective, Photochromic: Your cost will be limited to a copay that MetLife has negotiated for you. These copays can be viewed after enrollment at metlife.com/mybenefits. Contact lenses (instead of eyeglasses) Once every 12 months • Contact fitting and evaluation: Copay not to exceed $60 • Elective lenses: $130 allowance • Necessary lenses: Covered in Full after eyewear copay. We’re here to help Find a Vision provider at www.metlife.com/vision Download a claim form at www.metlife.com/mybenefits For general questions go to www.metlife.com/mybenefits or call 1-855-MET-EYE1 (1-855-638-3931)

200 Park Ave., New York, NY 10166 L0423030985[exp0426][All States] © 2024 MetLife Services and Solutions, LLC The following are optional benefit enhancements – Low Vision Once every 24 months Provides additional benefits to members who are not legally blind, but whose eyesight cannot be corrected to 20/70 with the use of optical lenses. Not available at retail chains including Costco®, Walmart® and Sam’s Club®. • Supplemental testing: Maximum of two (2) tests covered at no additional cost within a two (2) year period up to the benefit maximum. • Supplemental aids: 75% of the allowable amount up to the benefit maximum every two (2) years. • Benefit maximum: $1,000 every two (2) years. Diabetic Eyecare Plus Program Provides additional coverage for members who have been diagnosed with type 1 or type 2 diabetes and have specific ophthalmological conditions. It also provides benefits for those with glaucoma and age-related macular degeneration (AMD). In addition, members who have diabetes but don't show signs of diabetic eye disease are eligible to receive preventive retinal screenings. Not available at retail chains including Costco®, Walmart® and Sam’s Club®. • Exam: Covered in Full after $20 copay. • Special Ophthalmological services: Covered at no additional cost. Out-of-network reimbursement* You pay for services and then submit a claim for reimbursement. The same benefit frequencies for In-network benefits apply. Once you enroll, visit www.metlife.com/mybenefits for detailed out-of-network benefits information. • Eye exam: up to $45 • Single vision lenses: up to $30 • Progressive lenses: up to $50 • Frames: up to $70 • Lined bifocal lenses: up to $50 • Contact lenses: • Lined trifocal lenses: up to $65 • Elective up to $105 • Lenticular lenses: up to $100 • Necessary up to $210 *If you choose an out-of-network provider, you may have increased out-of-pocket expenses, must pay in full at time of service, and must file a claim for reimbursement. Low Vision: • Supplemental evaluation and aids: Same as in-network benefits. Diabetic Eyecare Plus Program: • Exam and other ophthalmological services - The lesser of the provider’s usual fee or up to 80% of the Medicare allowable charge.

200 Park Ave., New York, NY 10166 L0423030985[exp0426][All States] © 2024 MetLife Services and Solutions, LLC 1 All lens enhancements are available at participating private practices. Maximum copays and pricing are subject to change without notice. Please check with your provider for details and copays applicable to your lens choice. Please contact your local Costco, Walmart or Sam’s Club to confirm availability of lens enhancements and pricing prior to receiving services. Additional discounts may not be available in certain states. 2 Custom LASIK coverage only available using wavefront technology with the microkeratome surgical device. Other LASIK procedures may be performed at an additional cost to the member. Additional savings on laser vision care is only available at participating locations. Important: If you or your family members are covered by more than one health care plan, you may not be able to collect benefits from both plans. Each plan may require you to follow its rules or use specific doctors and hospitals, and it may be impossible to comply with both plans at the same time. Before you enroll in this plan, read all of the rules very carefully and compare them with the rules of any other plan that covers you or your family. Savings from enrolling in a MetLife Vision Plan will depend on various factors, including plan premiums, number of visits to an eye care professional by your family per year and the cost of services and materials received. Be sure to review the Schedule of Benefits for your plan’s specific benefits and other important details. Vision insurance is provided by Metropolitan Life Insurance Company, New York, NY (MetLife). Certain claims and network administration services are provided through Vision Service Plan (VSP), Rancho Cordova, CA. VSP is not affiliated with MetLife or its affiliates. Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, reductions, limitations, waiting periods, and terms for keeping them in force. Please contact MetLife or your plan administrator for costs and complete details.