PLAN BENEFITS - VSP PREFERRED PROVIDERS COVERED SERVICES Medical Eye Examinations: Covered in Full after a Copayment of $20.00. Urgent/Emergency Care* and Special Ophthalmological Services**: Covered in Full *Urgent/Emergency Care refers to VSP covered services for an emergency medical eye condition including, but not limited to eye infections, foreign body and abrasions, ocular injuries, and chemical exposure to the eye or eyelid. **Special Ophthalmological Services refer to eye care services that are problem-focused and involve medical decision- making. Special ophthalmological services go beyond general services and relate to the diagnosis, evaluation, treatment, and management of ocular conditions. EXCLUSIONS AND LIMITATIONS OF BENEFITS Supplemental Essential Medical Eye Care provides coverage for certain vision-related medical services as a supplement to Covered Person’s group medical plan. A current list of the covered procedures will be made available to the Client upon request. NOT COVERED 1. Eyeglasses or contact lenses. 2. General anesthesia surgical procedures. 3. Preoperative or postoperative surgical procedures. 4. Inpatient hospital services. 5. Services provided for refractive diagnoses that are part of the Covered Person's routine vision care coverage. 6. Prescription medication or supplies of any type. 7. Local, state and/or federal taxes, except where VSP is required by law to pay. 8. Services and/or materials not specifically included in this Rider as covered Plan Benefits. 20