UPMC Health Benefits, Inc. 2025_SOB_Vision_Care_LG 4O Page 4 of 8 Additional Lens Options Covered by Your Plan Lens Options Fixed Fee Progressives (add to bifocal base) Progressives – Tier 1 $60.00 Progressives – Tier 2 $90.00 Progressives – Tier 3 $110.00 Progressives – Tier 4 $125.00 Progressives – Tier 5 $145.00 Progressives – Tier 6 $170.00 Progressives – Tier 7 $190.00 Materials High Index Plastic 1.53-1.60/Trivex $50.00 High Index Plastic 1.66/1.67 $71.00 High Index Plastic 1.70 and above $80.00 Polycarbonate (Adults) $30.00 Aspheric Aspheric (Plastic/Poly) SV $30.00 Aspheric (Plastic/Poly) MF $35.00 Anti-Reflective Coating Anti-Reflective Coating – Tier 1 $45.00 Anti-Reflective Coating – Tier 2 $65.00 Anti-Reflective Coating – Tier 3 $85.00 Anti-Reflective Coating – Tier 4 $110.00 Polarized Polarized – Tier 1 $70.00 Polarized – Tier 2 $80.00 Polarized – Tier 3 $110.00 Polarized – Tier 4 $125.00 Polarized – Tier 5 $150.00 Polarized – Tier 6 $175.00 Photochromics Transitions VII $75.00 Transitions VII MF $90.00 Transitions XTRActive $110.00 Transitions Vantage $125.00 Near Variable Lenses Essilor Computer MF $65.00