Vision Insurance Benefit Summary

Page 1 Benefit plan and features Class definition: Class 1 – All Active Full Time Employees Coverage Details In-Network Benefit In-Network Copay Out-of-Network Benefit Frequency* Eye Examination Covered in full $10 Up to $ allowance 45 Every months 12 Prescription Eyeglasses $25 Frames **$ allowance 130 Included in prescription eyeglass copay Up to $70 Every months 24 Lenses Single Vision Lined Bifocal Lined Trifocal Lenticular Polycarbonate Lenses for Dependent Children Covered in full Included in prescription eyeglass copay Up to $30 Up to $50 Up to $65 Up to $100 N/A Every months 12 Elective Contact Lenses (in lieu of prescription eyeglasses) $ allowance for 130 contacts $0 Up to $105 Every months 12 Contact Lens Exam (fitting and evaluation) Up to $60 (discounted benefit) Group name: Betenbough Homes, LLC Policy number: 024883 Form created: 08/28/2025