Blue Mantis Vision Benefit Summary

SUMMARY OF BENEFITS VISION CARE IN-NETWORK OUT-OF-NETWORK SERVICES MEMBER COST MEMBER REIMBURSEMENT FRAME Frame $0 copay; 20% off balance Up to $75 over $150 allowance % STANDARD PLASTIC LENSES 40OFF Single Vision $25 copay Up to $25 Bifocal $25 copay Up to $40 additional complete pair Trifocal $25 copay Up to $60 of prescription eyeglasses Lenticular $25 copay Up to $60 Progressive - Standard $90 copay Up to $40 Progressive - Premium $90 copay; 20% off retail price Up to $40 less $120 allowance % LENS OPTIONS OFF Anti Reflective Coating - Standard $45 Not covered 20 Polycarbonate - Standard $40 Not covered non-covered items, Polycarbonate - Standard < 19 years of age $0 copay Up to $32 Scratch Coating - Standard Plastic $0 copay Up to $12 including non- Tint - Solid or Gradient $0 copay Up to $12 prescription sunglasses UV Treatment $0 copay Up to $12 All Other Lens Options 20% off retail price Not covered CONTACT LENSES Contacts - Conventional $0 copay; 15% off balance over Up to $120 $150 allowance Contacts - Disposable $0 copay; 100% of balance Up to $120 Find an eye doctor over $150 allowance (Select Network) Contacts - Medically Necessary $0 copay; paid in full Up to $200 OTHER • 866.299.1358 Hearing Care from Amplifon Network Discounts on hearing exam and Not covered • eyemed.com aids; call 1.877.203.0675 LASIK or PRK from U.S. Laser Network 15% off retail or 5% off promo Not covered • EyeMed Members App price; call 1.800.988.4221 • For LASIK, call FREQUENCY ALLOWED FREQUENCY - ALLOWED FREQUENCY - KIDS 1.800.988.4221 ADULTS Frame Once every 24 months Once every 24 months Lenses Once every 12 months Once every 12 months Heads Up Contact Lenses Once every 12 months Once every 12 months You may have (Plan allows member to receive either contacts and frame, or frames and lens services) additional benefits. Log into eyemed.com/member to see all plans included with your benefits. EyeMed reserves the right to make changes to the products available on each tier. All providers are not required to carry all brands on all tiers. For current listing of brands by tier, call 866.939.3633. No benefits will be paid for services or materials connected with or charges arising from: any Vision Examination; medical or surgical treatment, services or supplies for the treatment of the eye, eyes or supporting structures; services provided as a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof; orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; any corrective Vision Materials required by a Policyholder as a condition of employment; safety eyewear; solutions, cleaning products or frame cases; non-prescription sunglasses; plano (non-prescription) lenses; plano (non-prescription) contact lenses; two pair of glasses in lieu of bifocals; electronic vision devices; services rendered after the date an Insured Person ceases to be covered under the Policy, except when Vision Materials ordered before coverage ended are delivered, and the services rendered to the Insured Person are within 31 days from the date of such order; or lost or broken lenses, frames, glasses, or contact lenses that are replaced before the next Benefit Frequency when Vision Materials would next become available. Fees charged by a Provider for services other than a covered benefit and any local, state or Federal taxes must be paid in full by the Insured Person to the Provider. Such fees, taxes or materials are not covered under the Policy. Allowances provide no remaining balance for future use within the same Benefit Frequency. Some provisions, benefits, exclusions or limitations listed herein may vary by state. Plan discounts cannot be combined with any other discounts or promotional offers. In certain states members may be required to pay the full retail rate and not the negotiated discount rate with certain participating providers. Please see online provider locator to determine which participating providers have agreed to the discounted rate. Underwritten by Fidelity Security Life Insurance Company of Kansas City, Missouri, Policy number VC-19, form number M-9083, or Policy number VC-146, form number M-9184, in New York underwritten by Fidelity Security Life Insurance Company of New York, Policy Number VCN-1, form number MN-1, or Policy Number VCN-19, form number MN-28. This is a snapshot of your benefits. The Certificate of Insurance is on file with your employer.