DeltaVision 130 Standard - Benefits Overview

Bene昀椀ts overview1 Exam/lens/frame frequency (months) 12/12/24 DeltaVision® Contacts (instead of glasses) 12 130 Standard frequency (months) In-network coverage Exam copay $10 Materials copay (lenses and/or frame) $25 Single vision, lined bifocal, lined trifocal or Covered in full after copay lenticular lenses Frames allowance $130 Elective contact lenses allowance $130 Necessary contact lenses Covered in full after copay Contact lens 昀椀t and evaluation copay Up to $60 2 Out-of-network allowances Most popular lens enhancements (member cost) All lens enhancements are covered after a copay saving members 30% on average. Exam Up to $45 Single vision lenses Up to $30 Single Multifocal Bifocal lenses Up to $50 Standard anti-re昀氀ective coating $41 $41 Trifocal lenses Up to $65 Premium anti-re昀氀ective coating $68 $68 Progressive lenses Up to $50 Custom anti-re昀氀ective coating $85 $85 Lenticular lenses Up to $100 Polycarbonate lenses (adult) $35 $35 Frames Up to $70 Polycarbonate lenses (child) Covered Covered Elective contact lenses Up to $105 Standard progressive lenses N/A Covered Necessary contact lenses Up to $210 Premium progressive lenses N/A $95 or $105 Custom progressive lenses N/A $150 or $175 Photochromic lenses $75 $75 Scratch resistant coating $17 $17 3 Additional savings Frames discount An extra $20 allowance on featured designer brands for frames. 20% savings on any amount above the over allowance retail allowance. Additional pair 20% savings on unlimited additional pairs of prescription glasses and/or nonprescription sunglasses from any VSP network provider within 12 months of exam. LASIK Average 15% o昀昀 the regular price, or 5% o昀昀 the promotional price; discounts only available from contracted facilities. Retinal imaging Routine retinal screening covered after a maximum copay of $39. Essential Medical Supplemental coverage beyond routine care to treat urgent issues/monitor ongoing conditions like pink eye, SM Eye Care sudden vision changes, dry eye, diabetic eye disease and glaucoma. Low vision Pre-approved low-vision supplemental testing covered every two years. 75% coverage for approved low-vision aids, up to $1,000 (less any amount paid for supplemental testing) every two years. Eyeconic® Go to eyeconic.com® for an easy-to-use, convenient online eyewear option that integrates with your in-network bene昀椀ts. TruHearing® Save up to 60% on hearing aids and batteries. Visit truhearing.com/vsp or call 877-396-7194 for more information.4 Footnotes: www.deltadentalin.com/DeltaVision-footnotes FLI-6618-IN v3 Delta Dental of Indiana 130 STANDARD NO RATES C3 7/23