Prescription Eyewear Rider Kaiser Permanente Senior Advantage ( HMO) This rider is part of the Kaiser Permanente Senior Advantage (HMO) Evidence of Coverage (EOC) to which it is attached. All provisions of this rider become part of the EOC "Chapter 4: Medical Benefits Chart (what is covered and what you pay)" section. This entire benefit rider is therefore subject to all the terms and provisions of the EOC. We cover the services listed in this rider at network optical centers when prescribed by a network provider or an out-of-network provider. Eyeglasses and contact lenses We provide an allowance toward the price of prescription eyeglass lenses and a frame, or conventional or disposable prescription contact lenses, including medically necessary contact lenses. The allowance and your cost-sharing, if any, are listed in the Medical Benefits Chart "Vision care, Prescription eyewear" section. If the covered eyewear item you purchase costs more than the allowance for that item, you pay the difference. We will not provide the allowance if we have previously covered an eyewear item under this rider within the same allowance period. The date we cover any of these prescription eyewear items is the date on which you order the item. If you order the item while you are covered under this EOC, and if we would otherwise cover the item, we will cover the prescription eyewear item even if you do not receive it until after you are no longer covered under this EOC. If a network provider determines that one or both of your eyes has had a change in prescription of at least .50 diopters within 12 months after the date of your last exam where the "Prescription Eyewear Rider" benefit was used, we will provide an allowance toward the price of a replacement eyeglass lens or contact lens for each qualifying eye at the following maximum values: • $60 for single vision eyeglass lenses. • $60 for single vision contact lenses. • $90 for multifocal eyeglass lenses. • $90 for multifocal contact lenses. This replacement lens allowance is the same total amount whether you replace one lens or two. The replacement lenses must be the same type as the lenses you are replacing (eyeglass lenses or contact lenses). Medically necessary contact lenses Contact lenses may be determined to be medically necessary and appropriate in the treatment of the following conditions: • Keratoconus. • Pathological myopia. RSAVX2CY0124 1