UPMC Health Benefits, Inc. 2025_SOB_Vision_Care_LG 4O Page 6 of 8 Your vision plan includes the NVA EYEESSENTIAL® Discount Plan, which provides significant discounts on eyecare services and materials through participating NVA network providers. The fees listed on this document capture the discounted rate payable by the member. Not all Participating Vision Providers participate in the NVA EYEESSENTIAL® discount plan network. We encourage you to verify your provider’s participation in this network prior to receiving services. To see if your vision provider is participating visit www.upmchealthplan.com and select Find Care. • After enrolled Members have exhausted their benefits as described on the first page in this Schedule of Benefits, they are eligible to access the NVA EYEESSENTIAL® Plan discount on additional purchases during the Benefit Period. Please Note: The NVA EYEESSENTIAL® Plan is an in-network benefit only. Benefit frequency is unlimited, except for vision exams. The NVA EYEESSENTIAL® Plan discount program prices do not apply at retail locations. In certain states, Members may be required to pay the full retail amount and not the negotiated discount amount at certain participating providers. To see if your vision provider is participating in the NVA EYEESSENTIAL® Plan visit www.upmchealthplan.com and select Find Care. Service Material Member Discounted Cost Comprehensive Vision Examination (Including Dilation as Professionally Indicated) Once Every 12 Months $10.00 discount Lenses – Standard Glass or Plastic Single $35.00 Bifocal $55.00 Trifocal $70.00 Lenticular $70.00 Lens Options UV Coating $12.00 Tint ( Solid and Gradient) $12.00 Scratch-Resistant Coating (Standard) $15.00 Polycarbonate (Standard) $35.00 Anti-Reflective Coating (Standard) $45.00 Polarized $75.00 Transitions (Standard) Single Vision – $65.00 Bifocal and Trifocal – $70.00