Page 12 - WesternU Sample Guide

Vision Plan

VSP Vision | Vision Plan
Acorns provides vision coverage through VSP Vision. You can see an VSP Vision in-network provider or an out-of-network provider,
however, your costs will be lower if you visit an in-network provider. If you visit an in-network provider you will be responsible for
a copayment at the time of your service. If you receive services from an out-of-network doctor, you will pay all costs at the time of
service and submit a claim for reimbursement.

VSP Vision
Plan Name PPO

Network Name [Network Name] Non-Network
Vision Benefits

Copay
- Examination $10 Copay N/A
- Materials $10 Copay N/A
Examination (Every X Months) No Charge Up to $50 Reimbursement
Lenses (Every X Months)
- Single Vision No Charge Up to $50 Reimbursement
- Bifocal No Charge Up to $50 Reimbursement
- Trifocal No Charge Up to $50 Reimbursement
Frames (Every X Months) $130 Benefit Up to $50 Reimbursement
Contact Lenses (Every X Months) (in lieu of frames and lenses)

- Cosmetic / Elective $130 Benefit Up to $50 Reimbursement
- Medically Necessary No Charge Up to $50 Reimbursement
Laser Vision Correction Discounts Apply Not Covered

Finding a Vision Provider
Go to www.website.com. Refer to the [Network Name] network

The EyeMed network includes access to independent ophthalmologists and
optometrists, as well as LensCrafters®, Target Optical, Sears Optical, JCPenney Optical,
and most Pearle Vision retail stores.

Additional Discounts Available
LASIK and PRK Benefit: You are entitled to a 15% discount on the usual and customary fees for LASIK and PRK
procedures, or a 5% discount on any promotional pricing, whichever is the greater benefit, through the US Laser
Network.

Continued Eyewear Savings: After your initial visits have been utilized, you are able to receive ongoing discounts
on additional eye wear purchases at a network provider, which result in discounts up to 40% off the retail price
of eye wear and accessories.