Professional Fees/Materials Covered in full* Up to $210.00* Elective Elective Contact Lens Available once each 12 months** fitting and evaluation services are covered in full once every 12 months**, after a maximum $60.00 Copayment. Materials Professional Fees/Materials Up to $130.00 Up to $105.00 *Less any applicable Copayment. **Beginning with the first date of service. Necessary Contact Lenses are a Covered Services when specific benefit criteria are satisfied and when prescribed by Covered Person's In-Network Provider or Out-of-Network Provider. Review and approval by Delta Dental’s claims administrator is not required for Covered Persons to be eligible for Necessary Contact Lenses. Contact Lenses are provided in lieu of all other lens and frame benefits available herein. When contact lenses are obtained, the Covered Person shall not be eligible for lenses and frames again for 12 months. COVERED SERVICE OR IN- OUT-OF-NETWORK FREQUENCY MATERIAL NETWORK PROVIDER BENEFIT PROVIDER BENEFIT LOW VISION Professional services for severe visual problems not correctable with regular lenses, including: Supplemental Testing Covered in full Up to $125.00 * (Includes evaluation, diagnosis and prescription of vision aids where indicated.) Supplemental Aids 75% of amount 75% of amount * up to $1000.00* up to $1000.00* *Maximum benefit for all Low Vision services and materials is $1000.00 (excluding Copayment) every two (2) years. Low Vision benefits secured from Out-of-Network Providers (if covered) are subject to the same time and Copayment provisions described above for In-Network Providers. The Covered Person should pay the Out-of-Network Provider’s full fee at the time of service Covered Person will be reimbursed an amount not to exceed what would be paid to an In- Network Provider for the same services and/or materials. THERE IS NO ASSURANCE THAT THE AMOUNT REIMBURSED WILL COVER 75% OF THE PROVIDER’S FULL FEE. EXCLUSIONS AND LIMITATIONS Some brands of spectacle frames and lenses may be unavailable for purchase as Benefits, or may be subject to additional limitations. Members may obtain details regarding frame and lens brand availability from their In-Network Provider or by calling the Member Services Department at 1-800-877-7195. PATIENT LENS ENHANCEMENTS This Plan is designed to cover visual needs rather than cosmetic materials. When the Member selects any of the following extras, the Plan will pay the basic cost of the allowed lenses or frames, and the Member will pay the additional costs for the enhancements. VINPPOSUMM092022 3 KR#10267122