A Nationwide PPO Vision Plan

1 VSP Vision (800)807-07642022 A Nationwide PPO Vision Plan IMPORTANT Rates: Back Cover Summary of Benefits: Page 21 VSP Vision Care is available Nationwide and options: Standard Option - Self Only Standard Option - Self Plus One Standard Option - Self and Family High Option - Self Only High Option - Self Plus One High Option - Self and FamilyIntroduction On December 23, 2004, President George W. Bush signed the Federal Employee Dental and Vision Benefits Enhancement Act of 2004 (Public Law 108-496). The law directed the Office of Personnel Management (OPM) to establish supplemental dental and Vision benefit programs to be made available to Federal employees, annuitants, and their eligible family members. In response to the legislation, OPM established the Federal Employees Dental and Vision Insurance Program (FEDVIP). OPM has contracted with dental and Vision insurers to offer an array of choices to Federal employees and annuitants. Section 715 of the National Defense Authorization Act for Fiscal Year 2017 (FY 2017 NDAA), Public Law 114-38, expanded FEDVIP eligibility to certain TRICARE-eligible individuals.

2 This brochure describes the benefits of High Option and Standard Option with Vision Service Plan (VSP) under contract OPM02-FEDVIP-02AP-17 with OPM, as authorized by the FEDVIP law. The address for our administrative office is: VSP Vision Care 3333 Quality Drive Rancho Cordova, CA 95670 800-807-0764 brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your benefits. If you are enrolled in this plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus One, you and your designated family member are entitled to these benefits. If you are enrolled in Self and Family coverage, each of your eligible family members is also entitled to these benefits, if they are also listed on the coverage. You and your family members do not have a right to benefits that were available before January 1, 2022, unless those benefits are also shown in this negotiates benefits and rates with each carrier annually.

3 Rates are shown at the end of this brochure. VSP is responsible for the selection of doctors in their network. Visit or contact us at 800-807-0764 for a list of participating doctors. Continued participation with any specific doctor cannot be guaranteed. Thus, you should choose your plan based on the benefits provided and not on a specific provider s participation. When you phone for an appointment, please remember to verify that the provider is currently in-network. You cannot change plans because of changes to the provider network. Provider networks may be more extensive in some areas than others. We cannot guarantee the availability of every specialty in all areas. If you require the services of a specialist and one is not available in your area, please contact us for assistance. VSP and all other FEDVIP plans are not a part of the Federal Employees Health Benefits (FEHB) want you to know that protecting the confidentiality of your individually identifiable health information is of the utmost importance to us.

4 To review full details about our privacy practices, our legal duties, and your rights, please visit our website, , and click on the Patient Rights link at the bottom of the page. If you do not have access to the internet or would like further information, please contact us by calling 800-807-0764. Discrimination is Against the LawVSP Vision Care complies with all applicable Federal civil rights laws, to include both Title VII of the Civil Rights Act of 1964 and Section 1557 of the Affordable Care Act. Pursuant to Section 1557, VSP Vision Care does not discriminate, exclude people, or treat them differently on the basis of race, color, national origin, age, disability, or sex. Table of Contents How We've Changed for 2022 ..2 FEDVIP Program Highlights ..3 Section 1 Eligibility ..4 Section 2 Enrollment ..6 Section 3 How You Obtain Benefits ..10 Section 4 your Cost for Covered Services ..11 Section 5 Vision Services and Supplies ..12 Section 6 International Services and Supplies.

5 15 Section 7 General Exclusions Things We Do Not Cover ..16 Section 8 Claims Filing and Disputed Claims Processes ..17 Section 9 Definitions of Terms We Use in This Brochure ..19 Stop Health Care Fraud! ..20 Summary of Benefits ..21 Rate Information ..26 1 2022 VSP Vision Care Enroll at How We've Changed for 2022 Maximize your benefits with 'll get the highest value out of your VSP benefits when you visit a Premier Program location including private practice doctors and Visionworks retail locations. In addition to $0 copay for your eye exam at a Premier Program location, when you enroll in the High Option plan you'll get $250 to spend on featured frame brands or $250 to spend on any frame brand at Visionworks. Standard Option plan members get $200 to spend on featured frame brands or $200 to spend on any frame at Visionworks. Higher frame Option plan members now get a $200 frame allowance that can be used at any VSP network location. Standard Option plan members get a $150 frame allowance.

6 More provider choices for your yearly WellVision Exam . FEDVIP members can use their VSP Vision care benefit at Walmart and Sam's Club ! Standard Option members get $150 to spend on frames, and High Option members get $200 to spend on frames. protect your 20/20 prescription? No problem. your new LightCare benefit is included in both the Standard and High Option plans. If you don't need prescription eyewear, you can use your Vision benefits toward non-prescription ready-made sunglasses or blue light filtering glasses instead of prescription glasses or contacts. Keep your kiddos covered with 's Vision can change quickly, and we've got you covered when it does. Dependent children get two fully covered eye exams per year, and an additional set of lenses (or contacts) is covered in the same plan year, if needed. (Minimum prescription change is required, and any plan copays for exam and/or materials apply.) No copay for UV like the High Option plan, the Standard Option plan now covers UV coatings at no additional charge.

7 Essential Medical Eye Care is included in all benefit goes beyond routine eyecare and provides additional coverage for medical and urgent eyecare services things like glaucoma, diabetes, and age-related macular degeneration as well as diagnosis and treatment for conditions like pink eye. Stay the VSP app to check benefits and find a doctor anytime, anywhere. Available on the App Store and Google Play . Connect with us on social media @VSPV isionCare 2 2022 VSP Vision Care Enroll at FEDVIP Program Highlights You can select from several Nationwide , and in some areas, regional dental Preferred Provider Organization (PPO) or Health Maintenance Organization (HMO) plans, and high and standard coverage options. You can also select from several Nationwide Vision plans. You may enroll in a dental plan or a Vision plan, or both. Some TRICARE beneficiaries may not be eligible to enroll in both. Visit or for more information. A Choice of Plans and OptionsYou enroll online at Please see Section 2, Enrollment, for more information.

8 Enroll Through BENEFEDSIf you or one of your family members is enrolled in or covered by one FEDVIP plan, that person cannot be enrolled in or covered as a family member by another FEDVIP plan offering the same type of coverage; , you (or covered family members) cannot be covered by two FEDVIP dental plans or two FEDVIP Vision plans. Dual EnrollmentIf you sign up for a dental and/or Vision plan during the 2021 Open Season, your coverage will begin on January 1, 2022. Premium deductions will start with the first full pay period beginning on/after January 1, 2022. You may use your benefits as soon as your eligibility is confirmed. Coverage Effective DateEach year, an Open Season will be held during which you may enroll or change your Vision /dental plan enrollment. This year, Open Season runs from November 8, 2021 through December 13, 2021 (midnight EST). You do not need to re-enroll each Open Season, unless you wish to change plans or plan options; your coverage will continue from the previous year.

9 In addition to the annual Open Season, there are certain events that allow you to make specific types of enrollment changes throughout the year. Please see Section 2, Enrollment, for more information. Annual Enrollment OpportunityEmployees automatically pay premiums through payroll deductions using pre-tax dollars. Annuitants automatically pay premiums through annuity deductions using post-tax dollars. TRICARE enrollees automatically pay premiums through payroll deduction or automatic bank withdrawal (ABW) using post-tax Salary Deduction for EmployeesYour enrollment or your eligibility to enroll may continue after retirement. You do not need to be enrolled in FEDVIP for any length of time to continue enrollment into retirement. your family members may also be able to continue enrollment after your death. Please see Section 1, Eligibility, for more information. Continued Group Coverage After Retirement3 2022 VSP Vision Care Enroll at Section 1 Eligibility If you are a Federal or Postal Service employee, you are eligible to enroll in FEDVIP, if you are eligible for the Federal Employees Health Benefits (FEHB) Program or the Health Insurance Marketplace (Exchange) and your position is not excluded by law or regulation.

10 Enrollment in the FEHB Program or the Health Insurance Marketplace (Exchange) is not required. Federal EmployeesYou are eligible to enroll if you: Retired on an immediate annuity under the Civil Service Retirement System (CSRS), the Federal Employees Retirement System (FERS) or another retirement system for employees of the Federal Government; Retired for disability under CSRS, FERS, or another retirement system for employees of the Federal Government. your FEDVIP enrollment will continue into retirement if you retire on an immediate annuity or for disability under CSRS, FERS or another retirement system for employees of the Government, regardless of the length of time you had FEDVIP coverage as an employee. There is no requirement to have coverage for 5 years of service prior to retirement in order to continue coverage into retirement, as there is with the FEHB Program. your FEDVIP coverage will end, if you retire on a Minimum Retirement Age (MRA) + 10 retirement and postpone receipt of your annuity.