10 VISION Protect your sight and enjoy those sunsets even more with vision insurance. Receive both preventive and materials coverage. Hover over the insurance terms below to learn what they mean. PLAN I In Network Out of Network EYE EXAM $10 copay Up to $45 LENSES Single: Covered in full Bifocal: Covered in full Trifocal: Covered in full Lenticular: Covered in full Single: Up to $30 Bifocal: Up to $50 Trifocal: Up to $65 Lenticular: Up to $100 FRAMES $130-150 allowance depending on brand, then 20% savings on the amount over the allowance Up to $70 CONTACT LENSES Elective: $60 copay; $130 allowance Medically Necessary: $25 copay then covered in full Elective: Up to $30/50/65/100 depending on lense type Medically Necessary: Up to $210 FREQUENCY OF SERVICES Exams:1 X 12 Months Lenses: 1 X 12 Months Frames: 1 X 24 Months Contact Lenses: 1 X 12 Months Exams:1 X 12 Months Lenses: 1 X 12 Months Frames: 1 X 24 Months Contact Lenses: 1 X 12 Month RATES PER BI-MONTHLY PAY PERIOD Employee: $0.52 Employee + Spouse: $0.87 Employee + Children: $0.89 Family: $1.41 The benefits and rates in this guide are for illustrative purposes only. To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide, the underlying insurance documents will govern in all cases. REVIEW PLAN SUMMARY