Enrollment brochure

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Vision Insurance - GoldFreedom to choose any vision care provider

Network option for even greater savings

Annual eye exam and single or bifocal lenses at no cost from participating network providers

No deductibles

Highlights

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Offering Vision benefits does a lot more than provide employees with access to discounted eye wear. Regular eye exams can provide early detection of eye diseases, as well as health conditions like diabetes and high blood pressure. Highlights of our plans include:

• Members can choose any vision care provider but may pay less for services from network providers.• All members receive an annual eye exam and single or bifocal lenses at no cost from participating network providers.• No deductibles.

Participating Providers You have the freedom to visit the Vision Care provider of your choice, but out-of-pocket expenses may be reduced significantly when choosing a network provider. Our network has more than 40,000+ eye care professionals including retailers and independent doctors nationwide. Participating providers accept discounted fees for their services. So, when visiting a network provider, out-of-pocket expenses may be reduced significantly. Locate participating providers at: www.e-nva.com

Using the Network is easy No ID cards are required! In-network providers can easily verify member information and eligibility for services with-out an ID card, however for easy identification and reference, members may print them from their member portal.

No claim forms are needed for services from a participating network provider! Simply inform the providers office with the covered member’s ID number and/or name and date of birth.

The Network Advantage

Gold Plan Features

1Benefit year is based on member’s last date of service.2Actual discounted amounts may vary.3Does not apply at Contact Fill or Cole corporate locations (if applicable) and where prohibited by law. Prohibited by some manufacturers.4Prior authorization required.5Does not apply for certain proprietary frame brands and where prohibited by law.6Only covered if member chooses contact lenses.

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In-network benefits Out-of-network reimbursements

Exam Once every 12 months1

Covered 100% Up to $70Lenses Once every 12 months1

Single vision Covered 100% Up to $45 Bifocal vision Covered 100% Up to $115 Intermediate vision Covered 100% Up to $115 Trifocal Covered 100% Up to $190 Lenticular Covered 100% Up to $190Lens Options

Once every 12 months1

Scratch resistant coating Covered 100%

N/A

Fashion/gradient tint Covered 100% Solid tint Covered 100% Glass photogrey single vision lens Covered 100% Glass photogrey bifocal and trifocal lens Covered 100% Ultraviolet (UV) coating Covered 100% Standard anti-reflective (AR) coating Covered 100%

after $35 copay Polarized lenses Discounted to $752

Polycarbonate lenses Covered 100% Standard progressive lenses Covered 100% Premium progressive lenses Covered 100%

after $40 copayFrames Once every 12 months1

Frame allowance $175 retail allowance5 (20% overage discount) Up to $100

Contacts Once every 12 months1

(In lieu of eyeglasses)

Maximum allowance for conventional lenses $175 retail allowance (15% overage discount3)

Up to $290Maximum allowance for disposable lenses $175 retail allowance (10% overage discount3)

Medically necessary contact lenses4 Covered 100%Evaluation, fitting, and follow-up care - standard lens

Covered 100% after $20 copay

(daily wear lenses)6

N/ACovered 100% after $30 copay (ext. wear lenses)6

Evaluation, fitting, and follow-up care - specialty lens

Covered 100% after $50 copay6

You have the freedom to choose any vision care provider. When choosing an out-of-network provider, you’ll pay the fees for services and materials first to the provider at point of service and are then reimbursed according to your plan’s schedule.

Out-of-network claims:For services from an out-of-network provider, you may need to submit a claim form for reimbursement.

How it works Out-of-Network

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Once enrolled, all members receive access to register for their own online account at www.e-nva.com. Tools of the online member portal include:

• View eligibility information and print copies of ID cards• Search participating eyecare professionals in the area or nominate a preferred eyecare professional

(if not participating)• Submit, view, and check the status of claims• Find answers to our most frequently asked questions• Use the online tools previously described above in Additional Advantages from NVA

Online Member Tools

EYEESSENTIAL Plan After you have exhausted your funded benefit, you’re eligible to access significant discounts on materials through participating network providers.

NVA Smart Buyer The NVA Smart Buyer program provides you with the tools you need to become an educated consumer of vision care services and eye wear. It’s the only source that integrates your vision benefit coverage with the unbiased information you’ll need to maximize your vision benefit and reduce your out-of-pocket expense.

Vision Benefit Maximizer Eyecare Professional Search Tool Find an eyecare professional and view their service level (i.e. full service, exam only, etc.) and frame inventory (i.e. number of frames they have available including numbers of frames available at no out-of-pocket cost to you with your vision benefit, this service is exclusive to NVA’s Vision Benefit Maximizer).

NVA Smart Buyer’s Guide to Frames A detailed guide to the best approach for picking out eyeglass frames according to face shape, skin tone, eye and hair color, measurements, materials, and much more.

NVA Smart Buyer’s Guide to Eyeglass Lenses Use this guide to familiarize yourself with various eyeglass lens types, materials, lens coatings or treatments, enhance-ments, lens care and more.

Convenient home delivery of replacement contact lenses through Contact Fill

Laser Eye Surgery - The National LASIK Network Members are entitled to significant discounts and a free initial consultation with all in-network providers.

Additional Advantages from NVA

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Exclusions and Limitations

The information in this material is not intended as an offer of coverage. It is for illustrative purposes only, providing a general overview of featured benefit highlights provided under the policy. It is not a contract. The information in this material is not intended as an offer of coverage. It is for illustrative purposes only, providing a general overview of featured benefit highlights provided under the policy. It is not a contract. In the event of conflicting information with the policy, the policy will take precedence over what is shown in this material. The policy described in this material covers Vision benefits only. Not available in all jurisdictions. Policies are subject to Underwriting approval. All coverage extends up to policy limits. Policies are reviewed annually and may be cancelled for nonpayment. Please refer to the policy for coverage details, a complete listing of covered services, policy provisions, conditions, exclusions, and terms under which the policy may be continued or cancelled.

ShelterPoint is a registered Service Mark. All images licensed through iStockphoto.

Not available in all jurisdictions.

Underwritten by: ShelterPoint Insurance Company (licensed in 48 jurisdictions, not including NY) in: NJ (SPI GV0215 P NJ), PA (SPI GV0215 P PA)

This is a partial listing of benefits only. Please refer to the policy for details. No benefits are payable except as stated in the policy. This insurance does not apply to any expense for:

1. Cosmetic services or supplies; 2. Services rendered by a member of the treated person’s immediate household or family; 3. Treatment by someone not a licensed Optician, Optometrist, Ophthalmologist or a licensed medical practitioner; 4. Eye examinations for which benefits are paid or will be paid under any health care program supported in whole or in

part by funds of the federal government or any state or political subdivision; 5. More than one Vision Analysis, Vision Survey or refraction in any one Benefit Year; 6. Eye glasses or frames for which the Insured is reimbursed under any group hospitalization or medical expense reimbursement

plan, to the extent of such payment or reimbursement; 7. More than one pair of lenses or frames per person in any one Benefit Year; 8. Contact lenses provided for cosmetic purposes only; 9. Contact lens fitting examinations; 10. Non-prescription lenses, glasses or goggles; 11. Services performed as a result of any injury or illness covered by workers’ compensation; 12. Any service or treatment for which payment is not legally required; 13. Charges for broken or missed appointments; 14. Time spent completing insurance forms; 15. Treatment for intentionally self-inflicted injury; 16. Services or supplies that are not recommended by a Vision Provider; 17. Treatment for disease, defect, injury or loss caused by war or act of war, declared or not; or by a war-like act in time of peace; 18. Charges incurred as a result of illness or disease or accidental bodily injury; 19. In network co-payments whether incurred on this or any other vision benefit plan.