COVERED SERVICE OR IN-NETWORK OUT-OF-NETWORK FREQUENCY MATERIAL PROVIDER PROVIDER BENEFIT BENEFIT LENSES Available once each 12 months** Single Vision Covered in full * Up to $30.00* Lined Bifocal Covered in full * Up to $50.00* Lined Trifocal Covered in full * Up to $65.00* Lenticular Covered in full * Up to $100.00* Benefits for lenses are per complete set, not per lens. Polycarbonate lenses are covered in full for dependent children up to age 26. Standard Progressive Lenses covered in full. *Less any applicable Copayment. **Beginning with the first date of service. COVERED SERVICE OR IN-NETWORK OUT-OF-NETWORK FREQUENCY MATERIAL PROVIDER PROVIDER BENEFIT BENEFIT FRAMES Covered up to Plan Up to $70.00* Available once each 24 months** Allowance of $130.00* Frame Allowance may Frame Allowance may be be applied towards non- applied towards non- prescription sunglasses prescription sunglasses or or blue light filtering blue light filtering glasses, glasses, exhausting both exhausting both frame and frame and lens eligibility. lens eligibility. Lab-fabricated Lab-fabricated plano plano lenses are not covered. lenses are not covered. Benefits for lenses and frames include reimbursement for the following necessary professional services: 1. Prescribing and ordering proper lenses; 2. Assisting in frame selection; 3. Verifying accuracy of finished lenses; 4. Proper fitting and adjustments of frames; 5. Subsequent adjustments to frames to maintain comfort and efficiency; 6. Progress or follow-up work as necessary. Frame allowance may be applied towards non-prescription sunglasses for post PRK, LASIK, or Custom LASIK patients. *Less any applicable Copayment. **Beginning with the first date of service. COVERED SERVICE OR IN-NETWORK OUT-OF-NETWORK FREQUENCY MATERIAL PROVIDER PROVIDER BENEFIT BENEFIT CONTACT LENSES Necessary Available once each 12 months** VINPPOSUMM092022 2 KR#10267122