Using the Vision Care Plan

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RE: Provider Network Change for Vision Care Benefits

Dear Participant:

The UFCW Local 1776 and Participating Employers Health and Welfare Fund (hereinafter, “the Fund”), is pleased to announce a change to the Fund’s Vision Plan provider. Effective August 1, 2009, the Fund’s vision care provider is Liberty Vision Care, Inc. (hereinafter, “Liberty”).

Please note that the Plan’s vision benefits remain unchanged. However, in order to qualify for these vision benefits on or after August 1, 2009, you
MUST use a vision care provider who participates in Liberty Vision Care, Inc.’s provider network.

As you requested, enclosed is the Fund’s Vision Plan Claim Form, which
must be used within 60 days from its “DATE OF ISSUE”, as stated on the claim form, along with a list of Liberty Vision Care, Inc.’s participating providers (hereinafter, “participating providers”).

To use the Plan, select a participating provider and make an appointment. At the time of your appointment, bring the Fund’s Vision Plan Claim Form with you for completion at the time the service is rendered, and the participating provider will then submit the claim form to the Fund Office for review. Claim forms must be submitted to the Fund Office within 30 days from the date of the examination, so remember to follow-up with the provider to confirm that it is submitted timely.

If you would like to request that Liberty add a provider to its network, please complete and return the enclosed “Vision Provider Nomination Request” form to the Fund Office at 3031 B Walton Road, Plymouth Meeting, PA 19462.

If you have any questions regarding the Plan’s vision care benefits, or need assistance selecting a Liberty Vision Care, Inc. provider, please do not hesitate to contact the Fund Office at (610) 941-9400, ext. 126, or toll free at (800) 458-8618, ext. 126. You may also refer to your Summary Plan Description (“SPD”) booklet for a description of vision care benefits,

 Sincerely, The Fund Office