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)