Vision Benefits Summary

Intellisurvey, Inc. Group Vision Insurance Help protect your eye health with coverage for exams, glasses and contacts. This summary of benefits and coverage shows how you and The Standard would share the cost for covered vision care services. NOTE: This is only a summary; for detailed information on coverage, please consult your certificate of coverage. Plan 1: Balanced Care Vision I Plan Summary Effective Date: 1/1/2024 VSP Choice Network + Affiliates Out of Network Deductibles $10 Exam $10 Exam $25 Eye Glass Lenses or Frames* $25 Eye Glass Lenses or Frames Annual Eye Exam Covered in full Up to $45 Lenses (per pair) Single Vision Covered in full Up to $30 Bifocal Covered in full Up to $50 Trifocal Covered in full Up to $65 Lenticular Covered in full Up to $100 Progressive See lens options NA Contacts Fit & Follow Up Exams Participant cost up to $60 Not covered Elective Up to $150 Up to $120 Medically Necessary Covered in full Up to $210 Frame Allowance $150** Up to $75 Frequencies (months) Exam/Lens/Frame 12/12/24 12/12/24 Based on date of service Based on date of service *Deductible applies to a complete pair of glasses or to frames, whichever is selected. **The Costco and Walmart allowance will be the wholesale equivalent. Lens Options (participant cost)* VSP Choice Network + Affiliates Out of Network (Other than Costco) Up to provider’s contracted fee for Lined Progressive Lenses Bifocal Lenses. The patient is responsible Up to Lined Bifocal allowance. for the difference between the base lens and the Progressive Lens charge. Std. Polycarbonate Covered in full for dependent children Not covered $33 adults Solid Plastic Dye $15 Not covered (except Pink I & II) Plastic Gradient Dye $17 Not covered Photochromatic Lenses $31-$82 Not covered (Glass & Plastic) Scratch Resistant Coating $17-$33 Not covered Anti-Reflective Coating $43-$85 Not covered Ultraviolet Coating $16 Not covered *Lens Option participant costs vary by prescription, option chosen and retail locations. Standard Insurance Company

Intellisurvey, Inc. Monthly Rates Employee Only (EE) $5.50 EE + Spouse $11.66 EE + Children $12.31 EE + Spouse & Children $20.15 Additional Balanced Care Vision I Choice Network Features Allowance can be applied to disposables, but the dollar amount must be used all at once (provider will order 3 or 6 month supply). Applies when contacts are chosen in Contact Lenses Elective lieu of glasses. For plans without a separate contact fitting & evaluation (which includes follow up contact lens exams), the cost of the fitting and evaluation is deducted from the allowance. 20% off additional complete pairs of prescription glasses and/or prescription Additional Glasses sunglasses.* Frame Discount VSP offers 20% off any amount above the retail allowance.* VSP offers an average discount of 15% off or 5% off a promotional offer for LASIK Custom LASIK and PRK. The maximum out-of-pocket per eye for participants is Laser VisionCare $1,800 for LASIK and $2,300 for custom LASIK using Wavefront technology, and $1,500 for PRK. In order to receive the benefit, a VSP provider must coordinate the procedure. With prior authorization, 75% of approved amount (up to $1,000 is covered every two Low Vision years). Based on applicable laws, reduced costs may vary by doctor location. Domestic Partner California state law requires that coverage shall be provided to Registered Domestic Partners that is equal to, and subject to the same terms and conditions as, the coverage provided to a spouse. Registered Domestic Partner means a partner of the Insured as long as the partnership meets the requirements for such relationship as defined in Section 297 of the California Family Code or the functional equivalent registration of any other state or local jurisdiction. Vision Plan Participant Service Balanced Care Vision I from The Standard features the money-saving eye care network of VSP. Customer service is available to plan participants through VSP's well-trained and helpful service representatives. Call or go online to locate the nearest VSP network provider, view plan benefit information and more. VSP Call Center: 800.877.7195  Service representative hours: 5 a.m. to 7 p.m. Pacific Monday through Friday, 6 a.m. to 2:30 p.m. Pacific Saturday  Interactive Voice Response available 24/7 Locate a VSP provider at: www.standard.com/services Standard Insurance Company

Intellisurvey, Inc. About The Standard For more than 100 years, we have been dedicated to our core purpose: to help people achieve financial well-being and peace of mind. Headquartered in Portland, Oregon, The Standard is a nationally recognized provider of group employee benefits. To learn more about products from The Standard, visit us at www.standard.com. The Standard is a marketing name for StanCorp Financial Group, Inc. and subsidiaries. Insurance products are offered by Standard Insurance Company of Portland, Oregon, in all states except New York. Product features and availability vary by state and are solely the responsibility of Standard Insurance Company. This form is a benefit highlight, not a certificate of insurance. This policy has exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or terminated. Please contact The Standard or your employer for additional information, including costs and complete details of coverage. Standard Insurance Company