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