• 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