UPMC Health Benefits, Inc. 2025_SOB_Vision_Care_LG 4O Page 5 of 8 Lens Options Fixed Fee Specialty and Digital Single Vision Digital SV Tier 1 $100.00 Digital SV Tier 2 $145.00 Other Lens Treatments and Services Mirror – Solid and Single Gradient $60.00 Mirror – Double Gradient $70.00 Overpower (+6.00D or 3.00D Cylinder, per Lens) Included Add Power over 4.00D Included Prism over Range (over 3D per Eye) Included Press on Prism $30.00 Double Facetting $75.00 Facetted Lenses (includes Polish) $55.00 Slab Off $100.00 Rimless Drill $20.00 Groove Rimless Included Center Thickness Below 1.5 $16.50 Plastic Dyes – Solid $8.00 Plastic Dyes – Single Gradient $10.00 Plastic Dyes – Double/Triple Gradient $20.00 UV Protection $20.00 UV Protection – Backside (Add on to Front Side UV) $15.00 Scratch Resistant – Standard $15.00 Scratch Resistant TD2 $30.00 Scratch Resistant w/Optifog Technology $55.00 Edge Polish, Roll Edge, Roll & Polish $20.00 Edge Coating $30.00 Blue Light Blocking Lenses Blue Light Blocker - Tier 1 $40.00 Blue Light Blocker - Tier 2 $60.00 Blue Light Blocker - Tier 3 $120.00 Members receive a twenty (20%) percent discount on lens options not included in the schedule above. Fixed prices/discounts do not apply at Retail Locations. Discounts are not insured benefits. In certain states, Members may be required to pay the full retail amount and not the negotiated discount amount at certain participating providers.