REIMBURSEMENT SCHEDULE OPEN ACCESS PROVIDERS COPAYMENT There shall be a Copayment of $15.00 for the examination payable by the Covered Person at the time services are rendered. If materials (lenses, frames or Necessary Contact Lenses) are provided, there shall be an additional $25.00 Copayment payable at the time materials are ordered. The Copayment shall not apply to Elective Contact Lenses. COVERED SERVICES EYE EXAMINATION: Up to $ 45.00* once every 12 months** Comprehensive examination of visual functions and prescription of corrective eyewear. LENSES - Up to $30.00 - 100.00 * once every 12 months** Spectacle Lenses (Single, Lined Bifocal, Lined Trifocal or Lenticular) including Lens Enhancements (if purchased by Client). FRAMES: Covered up to $ 70.00* once every 24 months** CONTACT LENSES ELECTIVE Elective Contact Lenses are covered up to $105.00 once every 12 months** NECESSARY Necessary Contact Lenses are covered up to $210.00* once every 12 months** Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's Doctor. Contact Lenses are provided in place of spectacle lens and frame benefits available herein. *Less any applicable Copayment. **beginning with the first day of the Benefit Period. 10