Avesis Benefit Summary 2024

UnityPoint Health Group #60790-1056 UnityPoint - Meriter Group #60790-1751 Plan #065175CZL6 Effective Date: 1/1/2024 Out-of-Network Reliable & Dependable Vision Care Services In-Network Member Cost Reimbursement Avēsis provides exceptional Vision Examination vision care benefits for Includes refraction Coveredinfullafter $10 copay Up to $35 millions of commercial members throughout Retinal Imaging Up to $45 member out-of-pocket (OOP) maximum N/A the country. Materials $10copay The Avēsis vision care (Materials copay applies to frame or spectacle lenses, if applicable.) products give our members Frame Allowance an easy-to-use vision benefit Up to 20% discount above Members receive a $65 wholesale allowance Up to $55 that provides excellent frame allowance.* up to $175 retail value† value and protection. Standard Spectacle Lenses Single Vision Coveredinfullafter $10 copay Up to $25 Rates Bifocal Coveredinfullafter $10 copay Up to $40 EmployeePaid-Monthly Trifocal Coveredinfullafter $10 copay Up to $50 EmployeeOnly $7.13 Lenticular Coveredinfullafter $10 copay Up to $80 Employee+Spouse $13.70 Employee+Child(ren) $15.51 Preferred Pricing Options Level 6 Option Package Employee+Family $20.32 (Single Vision/Multi-Focal) $40/$44(Coveredinfulluptoage19) N/A(Upto$10for Polycarbonate agesupto19) Standard Scratch-Resistant Coating $17 N/A How can we help you? Ultraviolet Screening $15 N/A Avēsis Website: Solid or Gradient Tint $17 N/A www.avesis.com Standard Anti-Reflective Coating $45 N/A Customer Service: Level 1 Progressives Coveredinfull Upto$40 855-214-6777 Level 2 Progressives Coveredinfull Upto$48 7 a.m. - 8 p.m. EST All Other Progressives $140allowance+upto20%discount Upto$48 LASIK Provider: (Single Vision/Multi-Focal) $70/$80 N/A Transitions® 877-712-2010 Polarized $75 N/A PGX/PBX $40 N/A Other Lens Options Up to 20% discount* N/A †  Value may be less depending on the providers retail pricing. Contact Lenses (in lieu of frame and spectacle lenses) *  Discounts are not insured Elective $175allowance Up to $160 benefits. Medically Necessary‡ Covered in full Up to $250 ‡  Enhanced benefit for certain conditons. ¥ Refractive Laser Surgery   Save up to 25% on average Onetime/lifetime $150 allowance Onetime/lifetime LASIK prices when you use Up to 25% provider discount ¥ Qualsight (visit qualsight.com/- Provider discount up to 25%* $150allowance avesis for more information). Frequency + At participating Walmart/ Sam's locations, retail pricing for your plan is . Eye Examination Once every 12months $68 Lenses or contact lenses Once every 12months At participating Costco locations, retail pricing Frame Once every 24months $69.99 is . Avǖsis vision insurance products are underwritten by Fidelity Security Life Insurance Company® (FSL), Kansas City, MO, when insured by FSL. Approved by FSL date of 11/23. Administered by Avǖsis. Policy # VC-16, Form M-9059. AVE-440 ©2023 Avēsis, LLC. All Rights Reserved. rev10202023

Here′s How It Works When you need to see an eye care professional, simply visit www.avesis.com or contact Avēsis’ Customer Service Monday through Friday, 7 a.m. to 8 p.m. (EST) at 8-- to receive a listing of providers in your area. Select Make an Visit the provider Pay any copays or 1234 a provider appointment for service additional expenses Using Out-of-Network Providers Exclusions Members who elect to use an out-of-network provider must No benefits will be paid for services or materials connected pay the provider in full at the time of service and submit with or charges arising from: a claim to Avēsis for reimbursement. Reimbursement levels 1. Orthoptic or vision training, subnormal vision aids, and are in accordance with the out-of-network reimbursement any associated supplemental testing; Aniseikonic lenses; schedule previously listed. Out-of-network benefits are 2. Medical and/or surgical treatment of the eye, eyes, or subject to the same eligibility, availability, frequency of supporting structures; benefits, and limitation and exclusion provisions of the plan, and are in lieu of services provided by a participating 3. Any Vision Examination, or any corrective eyewear, Avēsis provider. Out-of-network claim forms can be required by an Employer as a condition of employment obtained by contacting Avēsis’ Customer Service Center or and safety eyewear, unless specifically covered under your group administrator, or by visiting www.avesis.com. the Policy; Termination Provisions 4. Services provided as a result of any Workers’ The coverage will continue as long as the group policy Compensation law, or similar legislation, or required by remains in force, the premiums are paid, and as long as the any governmental agency or program whether Federal, employee and any covered dependents remain eligible and state, or subdivisions thereof; the employees coverage remains in force. 5. Plano (non-prescription) lenses; Notes and Disclaimers 6. Non-prescription sunglasses; The contact lens allowance may be used all at once or 7. Two pair of glasses in lieu of bifocals; or throughout the plan year as needed or may be applied 8. Services or materials provided by any other group toward contact lenses only, or both contact lenses and benefit plan providing vision care. professional services (fitting fees). Refractive Laser Surgery Lost or broken lenses, frames, glasses, or contact lenses is considered an elective procedure, and may involve will not be replaced except in the next Benefit Period when potential risks to patients. Avēsis is not responsible for the Vision Materials would next become available. outcome of any refractive surgery. Discounts on materials are not available at Walmart locations. Members may not Refractive Surgery Vision Benefit Exclusions use their contact lens allowance toward fitting fees at Benefits are not payable for any of the following: Walmart and are responsible for any out-of-pocket fees 1. Routine vision examinations or corrective vision associated with fittings there. Discounts on materials are materials, including corrective eyeglasses, fittings, not available at Costco locations. ID cards are not required lenses, frames, or contact lenses; or for services. Limitations and Exclusions 2. Medical or surgical procedures, services, or treatments: Some provisions, benefits, exclusions, or limitations listed a. not specifically covered under this Rider; herein may vary depending on your state of residence. b. provided free of charge in the absence of insurance Limitations c. payable under any Workers’ Compensation law or This plan is designed to cover eye examinations and similar statutory authority corrective eyewear. It is also designed to cover visual d. payable under governmental plan or program, needs rather than cosmetic options. Should the member whether Federal, state, or subdivisions thereof. select options that are not covered under the plan, as shown in the schedule of benefits, the member will pay a discounted fee to the participating Avēsis provider. Benefits are payable only for services received while the group and individual member’s coverage is in force. Avēsis Insured benefits are administered by Avēsis Third Party Administrators, Inc., Phoenix, AZ WҼW[pdekcqlkSqo``qҿ AVE-440 ©2023 Avēsis, LLC. All Rights Reserved. rev10202023 Suite ҿ T`jm`, AZ 85