C. VISION BENEFITS (APPLICABLE TO ALL MEMBERS AND DEPENDENTS)

Vision benefits, available to all Active and Retiree members and their Dependents, are self-funded and administered by Vision Service Plan, Group #12140808.

1. Co-Payment and Services Available.

If you use a participating Vision Service Plan (“VSP”) provider, you will be responsible for a $10.00 co-payment plus additional payment for certain cosmetic or elective eyewear options. Benefits include examination and new lenses (for glasses and contacts) every 12 months, and new frames every 24 months. In addition, the Plan provides a 20% discount on non-covered complete pairs of prescription glasses when provided by a VSP provider. A complete listing of VSP participating providers is available in the Plan Office. You may also contact VSP’s customer service at (800) 877-7195 or you can visit the company’s web site at www.vsp.com.

2. How to use the Plan.

Call your VSP provider to make an appointment. Identify yourself as a San Francisco Electrical Workers Health & Welfare Plan VSP member and provide your name, date of birth, and Social Security number. The provider will then verify your eligibility and will deal directly with VSP for reimbursement for services and materials that are covered by the Plan. You simply pay your providers for the co-payment and any other costs that are not covered.

3. Out-of-Network Providers.

Although, typically more than 90 percent of patients receive care from VSP providers, VSP will reimburse you up to the amount allowed under the Plan’s out-of-network provider reimbursement rate if you are treated by a provider outside of the VSP network.

OUT-OF-NETWORK Maximum Benefits:

A copy of the provider’s itemized bill with all of the pertinent Plan and patient information should be submitted directly to Vision Service Plan, Attn.: Out-of-Network Claims, P. O. Box 997100, Sacramento, CA 95899-7100.