DeltaVision Summary of Vision Plan Benefits for Elkhart Community Schools

DeltaVision Summary of Vision Plan Benefits For Group# V1300-0001, 0002, 0099 Elkhart Community Schools This Summary of Vision Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your DeltaVision plan. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the Provider’s network participation.* Control Plan – Delta Dental of Indiana Benefit Year – January 1 through December 31 Delta Dental will provide vision care Benefits according to the Schedule listed below. This Schedule lists the vision care Benefits to which Members are entitled, subject to any applicable Copayments and other conditions, limitations and/or exclusions stated herein. Administrative Services for the adjudication of claims and the payment of Benefits under this Policy will be provided by Vision Service Plan Insurance Company (

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

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

• Optional cosmetic processes. • Anti-reflective coating. • Color coating. • Mirror coating. • Scratch coating. • Blended lenses. • Cosmetic lenses. • Laminated lenses. • Oversize lenses. • Polycarbonate lenses. • Photochromic lenses, tinted lenses except Pink #1 and Pink #2. • Progressive multifocal lenses. • UV (ultraviolet) protected lenses. • Certain limitations on low vision care. NOT COVERED There are no Benefits for professional services or materials connected with: • Orthoptics or vision training and any associated supplemental testing. • Plano lenses (less than a ± .50 diopter power). • Two pair of glasses in lieu of bifocals. • Replacement of lenses and frames furnished under this Plan that are lost or broken, except at the normal intervals when services are otherwise available. • Medical or surgical treatment of the eyes. • Corrective vision treatment of an Experimental Nature. • Costs for services and/or materials above stated allowances. • Services and/or materials not indicated on this Schedule as covered Plan Benefits. • Contact lens modification, polishing or cleaning. • Local, state and/or federal taxes, except where Delta Dental or its claims administrator is required by law to pay. • Replacement of lost or damaged contact lenses, except at the normal intervals when services are otherwise available. Co-Payment – There shall be a Copayment of $10 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 Copayment payable at the time materials are ordered. The Copayment shall not apply to Elective Contact Lenses. Lens Enhancements, if covered under this Policy, may have a separate Copayment. Please refer to COVERED SERVICES AND MATERIALS, above. Waiting Period – Certified Employees are eligible for coverage on the 1st of the month following date of hire. Classified Employees are eligible for coverage on the 1st day of the month after meeting the 60 day waiting period for employment. Eligible People – All active full-time & part-time Certified and Classified employees who work 30 or more hours per week (0001), retired teachers who have at least 15 years of service and are at least 55 years of age, retired teachers who have at least 10 years of service and are at least 60 years of age, retired administrators who have at least 10 years of service and are at least 55 years of age, retired classified employees who have at least 15 years of service and are at least 55 years of age, retired classified employees who have at least 10 years of service and are at least 60 years of age (0002) and (Consolidated Omnibus Budget Reconciliation Act of 1985) enrollees (0099), if applicable, who choose the Vision Plan. Also eligible are your Spouse and your Children to the end of the calendar year in which they turn 26, including your Children who are married, who no longer live with you, who are not your dependents for Federal income tax purposes, and/or who are not permanently disabled. Enrollees and dependents choosing this plan are required to remain enrolled for a minimum of 12 months. Should an Enrollee or Dependent choose to drop coverage after that time, he or she may not re-enroll prior to the date on which 12 months have elapsed. Dependents may only enroll if the Enrollee is enrolled (except under COBRA) and must be enrolled in the same plan as the Enrollee. An election may be revoked or changed at any time if the change is the result of a qualifying event as defined under Internal Revenue Code Section 125. VINPPOSUMM092022 4 KR#10267122

Coordination of Benefits – If you and your Spouse are both eligible to enroll in This Plan as Enrollees, you may be enrolled together on one application or separately on individual applications, but not both. Your Dependent Children may only be enrolled on one application. Delta Dental will not coordinate Benefits between your coverage and your Spouse's coverage if you and your Spouse are both covered as Enrollees under This Plan. Benefits will cease at the end of the month of your date of termination. Customer Service Toll-Free Number: 800-877-7195 If you’re hearing impaired, call 800-428-4833 www.VSP.com January 1, 2024 VINPPOSUMM092022 5 KR#10267122